Ambulatory Patient Services (EHB) (Cont’d) Appeals Procedures Resources: ; Internal appeals / review of adverse benefit decisions Both and plans 42 U.S.C. §300gg-19 (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? Non-Grand- fathered Grand-
The issuer furnishes the appellant or their representative with a paper version of the electronically furnished documents if requested. Expedited Internal Reviews of Adverse RCW 48.43.530(5)(c) WAC The Issuer must provide an expedited review process at any in the review process IF: Benefit under WAC The appellant is currently receiving or is prescribed treatment or benefits that would end due to the adverse benefit determination; OR Fathered Plans 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 Appeals Procedures (Cont’d) Expedited Internal Reviews of Adverse 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. Benefit under Non- WAC If the treating health care provider determines that a delay 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. Fathered (Cont’d) 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.
and plans RCW 48.43.535(2) WAC Enrollee may also seek review by a certified independent review organization the carrier has exceeded the timelines provided in RCW 48.43.530, without good cause and without reaching a decision. WAC Issuers must use the rotational registry system of certified independent review organizations (IROs) established by OIC, and may not make an assignment to an IRO out of sequence for any reason other than the existence of a conflict of interest, as set forth in WAC Issuers must make available to the enrollee and to any provider acting on behalf of the enrollee all materials provided to the IRO. Appeals Procedures (Cont’d) Independent Review of appeals (“IRO”) for both and WAC Issuers must provide IROs with all relevant clinical review criteria used by the issuer and relevant medical, scientific, and evidence, the attending or ordering provider's recommendations, and a copy of the terms and conditions of coverage under the relevant health plan. plans (Cont’d) RCW 48.43.535(5) Enrollees must have at least five business days to submit to the independent review organization in writing additional information that the independent review organization must consider when conducting the external review. RCW 48.43.535(7)(a) An enrollee or carrier may request an expedited external review if the issuer’s decision to deny, modify, reduce, or terminate coverage or payment for a health care service: concerns an admission, availability of care, continued stay, or health care service for which the claimant received emergency services but has not been discharged from a facility; or involves a medical condition for which the standard external review time frame would seriously jeopardize the life or health of the effectiveness
Reasonable Medical Management WAC Plan may include reasonable medical management to control costs, including promoting the use of appropriate, high value preventive services, providers and settings. Plan must permit waiver of an otherwise applicable copayment for a service that is tied to one setting but not the preferred high-value setting, if the enrollee's provider determines that it would be medically inappropriate to have the service provided in the setting. Issuer may still apply applicable in-network requirements. Contracting for Outside Services RCW 48.43.085 Contract must state that the issuer may not prohibit enrollees from freely contracting to obtain any health care services outside the plan on any terms the enrollees choose. No Annual or Lifetime Dollar Limits WAC An issuer must not impose annual or lifetime dollar limits on an essential health benefit, other than those specifically permitted under WAC 284-43-5702 and 284-43-5782. Discretionary Clauses Prohibited Discretionary Clauses Prohibited (Cont’d) RCW 48.46.060(2) Contract must not purport to give the HMO or any designee authority to make a decision on the contract, or coverage or claims thereunder, is final and binding on the enrollee. RCW 48.46.060(3)(a) Contract may not contain a “discretionary clause” that purports to reserve discretion to a carrier or its designees to interpret the contract or decide eligibility for benefits, or requires deference to such interpretations or decisions. WAC Specific prohibited provisions: That the carrier's interpretation of the terms of the contract is binding; WAC That the carrier's decision regarding eligibility or continued receipt of benefits is binding;
Contract Standards Required (Cont’d) Contract Standards If an issuer chooses to adopt this premium clawback practice, the enrollment or application materials must clearly describe the consequences of non-payment on future enrollment. See, also, 82 FR 18346, 18350 (4/18/2017).
(d) requirements; 48.43.510(1) (e) summary explanation of the carrier's review of adverse benefit determinations and grievance processes; 48.43.510(1) (f) statement regarding the availability of a point-of-service option, if any, and how the option operates; and 48.43.510(1) (g); convenient means 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. RCW 48.43.510(2)(a) Contract must contain the following written information or notify the enrollee that he is entitled to it upon request: Any documents, instruments, or information referred to in the medical coverage agreement; RCW 48.43.510(2)(b) A full description of the procedures to be followed by an enrollee for consulting a provider than the primary care provider and whether any entity must authorize the referral; RCW 48.43.510(2)(c) Procedures, if any, that an enrollee must first follow for obtaining prior authorization for health care services; RCW 48.43.510(2)(d) A written description of any reimbursement or payment arrangements between the issuer and providers, including capitation provisions, provisions, and health care delivery efficiency provisions; RCW 48.43.510(2)(e) 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; RCW 48.43.510(2)(f) An annual accounting of all payments made by the carrier which have been counted against any payment limitations, visit limitations, or other overall limitations on a person's coverage under a plan; and
Emergency Medical Services (EHB) (Cont’d) Every Category of Provider Requirements 42 U.S.C. §300gg-5(a) See Plan and Issuer must not discriminate with respect to participation 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); RCW 48.43.515(1) Every category of provider must be permitted to provide covered services, if the treatment is within the scope of the provider’s licensure. Each enrollee must have adequate choice among providers. WAC 284-43-9970(2) / WAC 284-170-200(2); WAC 284-43-9975(1) / WAC 284-170-270(1) WAC Each health plan’s defined service area must have a comprehensive 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. WAC Each enrollee must have adequate choice health care providers, including those providers which must be included in the network under WAC 284-170-270 for qualified health plans and qualified stand-alone dental plans under WAC 284-170-310. WAC 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.
Experimental or Investigational Treatment (Cont’d) Requirements (Cont’d) WAC WAC (1) Whether the claim or request for preauthorization is made in writing or through other claim presentation or preauthorization procedures set out in the contract, any denial because of an experimental or investigational exclusion or limitation, must be done in writing within twenty working days of receipt of a fully documented request. The issuer may extend the review period beyond twenty days only with the informed written consent of the enrollee. Grievance Procedures RCW 48.43.005 (21) WAC (11) WAC "Grievance" means a written complaint submitted by or on behalf of an enrollee regarding service delivery issues other than denial of payment for, or nonprovision of, medical services, including dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or dissatisfaction with service provided by the health carrier. RCW 48.43.530(8) Contract must provide a clear explanation of the grievance process. Process must be accessible to enrollees who are limited English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to file a grievance. RCW 48.43.530(9)
Mental Health and Substance Use Disorder (MH/SUD) Services, Including symptoms of tolerance or physiological and/or psychological withdrawal if use of the controlled substance or alcoholic beverage is reduced or discontinued; and the user's health is substantially impaired or endangered or his or her social or economic function is substantially disrupted. Any disorder defined by the plan as being or as not being a substance use disorder must be defined to be consistent with generally recognized independent standards of current medical practice (for example, the most current version of the DSM, the most current version of the ICD, or state guidelines).” Mental Health Parity Mental Health Parity (Cont’d) P.L. 110-343 Plan may not any financial requirement or treatment limitation to MH/SUD benefits that is more restrictive than those applied to medical/surgical benefits. (Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”)) RCW 48.46.291 (2)(c)(i) The copayment or coinsurance for mental health services may be no more than the copayment or coinsurance for medical and surgical services otherwise provided the health benefit plan. Preventive services are excluded from this comparison. RCW 48.46.291 (2)(c)(i) If the plan has a maximum out-of-pocket or stop loss, it must be for medical, surgical, and mental health - it cannot have a separate MOOP or stop loss for mental health. RCW 48.46.291 (2)(c)(i) If the plan has any deductible, it must be for medical, surgical, and mental health – it cannot have a separate deductible for mental health. RCW 48.46.291 (2)(c)(ii) Prescription drugs intended to treat any MH/SUD disorder must be covered to the same extent, and under the same terms and conditions, as other covered prescription drugs. RCW 48.46.292 No preauthorization is required for mental health treatment rendered by a state hospital if the enrollee or covered dependent is involuntarily
Mental Health Parity (Cont’d) 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. WAC WAC 284-43-7010 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: WAC Quantitative treatment limitations: expressed numerically (such as fifty outpatient visits per year) Includes annual, episode, and lifetime day and visit limits. WAC Nonquantitative treatment limitations (“NQTL”): processes, strategies, or evidentiary standards, or other factors that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. Includes, but not limited to: WAC (a) Limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (b) Formulary design; (c) For plans with multiple network tiers (such as preferred providers and participating providers), network tier design; (d) Standards for provider admission to participate in a network, including reimbursement rates; (e) Methods for determining customary, and reasonable charges; (f) Use of fail-first policies or step therapy protocols; (g) Exclusions on failure to complete a course of treatment; and
(Cont’d) 45 CFR § 92.8(a)(5) Contract must identify and provide contact information for the responsible employee designated to coordinate its nondiscrimination efforts, including complaints. 45 CFR § 92.8(a)(6) and (7) Contract must notify enrollee of the availability of the grievance procedure and how to file a grievance, and how to file a discrimination complaint with the federal Office of Civil Rights. Taglines 45 CFR § 92.8(d)(1) Contract must include taglines in at the top 15 languages spoken by individuals with limited English proficiency of the relevant State or States. Pediatric Oral Services (EHB) Pediatric Oral Services (EHB) Requirement to Cover Requirement to Cover Pediatric Oral Services (Cont’d) 42 USC §1802(a)(1)(B) 42 USC 18022(b)(1)(J) ATTENTION: Plans sold on the Exchange CAN NOT contain Pediatric Dental benefits as an embedded set of benefits. A health plan sold outside the Exchange may include pediatric dental benefits as an embedded set of benefits, or through a combination of a health benefit plan and 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 “2017 ALL FILERS Individual EMBEDDED Pediatric Dental EHBs Analyst 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 stand-alone QDP. This reasonable assurance must be received by the issuer within 60 days. Pediatric Vision Services (EHB) Requirement for Coverage WAC - 2) Plan must cover pediatric vision services as an embedded set of services. Discrimination
Drug Exception Process (Cont’d) 45 CFR 156.122 (c)(2)(iii) Plan must make its determination on an expedited review request and notify the enrollee (or designee) and prescriber of its determination no later than 24 hours following receipt of the request. WAC 284-43-5080(3)(c)(i) 45 CFR 156.122 (c)(2)(iv) If exception is granted, plan must provide coverage of the drug for the duration of the exigency. WAC 45 CFR 156.122 (c)(3)(i) External exception request review. If the Plan denies a request for a standard exception or an expedited exception, the plan must have a process for the enrollee, the enrollee's designee, or the enrollee's prescriber to request that the original exception request and subsequent denial of such request be reviewed by an independent review organization. WAC 45 CFR 156.122 (c)(3)(ii) Plan must make its determination on the external exception request and notify the enrollee (or designee) and the prescriber of its determination no later than: WAC 284-43-5080(6)(a) 72 hours following its receipt of the request, if the original request was a standard exception request, and 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 non-formulary drug for the duration of the prescription. WAC 284-43-5080(6)(b) 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 non-formulary drug for the duration of the exigency. WAC 284-43-5080(6)(b)
Prohibited Wellness Limitations Prohibited Wellness Limitations (Cont’d) 42 USC (a) Plan may not include cost requirements with respect to the preventive services listed under WAC 284-43-5642(9) (b)(i) through (iv) that are provided in-network. (WAC 284-43-5642(9)(d)) WAC The provider network must include preventive and wellness services, including chronic disease management and smoking cessation services as defined in RCW (37) and WAC (9) and (9). If these services are provided through a quit-line or help-line, the issuer must ensure that when follow-up services are medically necessary, the enrollee will have access to sufficient information to access those services within the service area. Contracts with quit-line or help-line services are subject to the same conditions and terms as other provider contracts under this section. WAC Plan must cover medically necessary neurodevelopmental therapy for any DSM diagnosis without blanket exclusions. (e.g., Plan may not limit outpatient neurodevelopmental therapy services to person’s age six and under.) benefit requirements classified in Preventive and Wellness Services RCW 48.43.043 (1)(b)(i) (1)(b)(ii) State benefit requirements classified in this category are: Colorectal cancer screening. WAC 284-43-5642(9)(e)(i) For a covered individual who is at least 50 years old; Less than 50 and at high risk or very high risk for colorectal cancer. RCW 48.46.275 Mammogram services, both diagnostic and screening to include Tomosynthesis. WAC 284-43-5642(9)(e)(ii), SB 5912 Plan can apply standard contract provisions for diagnostic mammograms applicable to other benefits such as deductible cost sharing. E.g., may apply deductible and copay requirements; and RCW 48.46.277(1) Prostate cancer screening if delivered upon the recommendation of the patient’s physician, ARNP, or Physician Assistant. WAC
Preventive and Wellness Services, Including Chronic Disease Management (EHB) (Cont’d) State benefit requirements classified in Preventive and Wellness Services (Cont’d) RCW 48.46.250; WAC (10)(a)(ii) Treatment of congenital anomalies in newborn and dependent children. This benefit requirement may be classified to hospitalization, ambulatory patient services or maternity and newborn categories.
Rehabilitative and Habilitative Services (EHB) (Cont’d) WAC Durable medical equipment and mobility enhancing equipment used to serve a medical purpose, including sales tax. Optional Rehabilitative and Habilitative Services WAC 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: 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 than cochlear implants. Habilitative Services Definition WAC For purposes of determining a plan's AV, issuer must classify as habilitative services the 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 parity between Habilitative and Rehabilitative services 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. WAC However, when habilitative services are delivered to treat a mental health diagnosis categorized in the most recent version of the DSM, the
Rehabilitative and Habilitative Services (EHB) (Cont’d) Prohibition on limitations of medically necessary coverage for chronic conditions or diseases WAC An issuer must not classify services to the rehabilitative services category if the classification results in a limitation of coverage for therapy that is medically necessary for an enrollee's treatment for cancer, chronic pulmonary or respiratory disease, cardiac disease or other similar chronic conditions or diseases. For purposes of this requirement, an issuer must establish limitations on the number of visits and coverage of the rehabilitation therapy consistent with its medical necessity and utilization review guidelines for medical/surgical benefits. (e.g., breast cancer rehabilitation therapy, respiratory therapy, and cardiac rehabilitation therapy.) Such services may be classified to the ambulatory patient or hospitalization services categories for purposes of determining actuarial value.
RCW 48.43.735(4) Any originating site may charge a facility fee for infrastructure and preparation of the patient. Reimbursement must be subject to a negotiated agreement between the originating site and the health plan. A distant site or any other site not identified above may not charge a facility fee. RCW 48.43.735(5) Plan may not distinguish between originating sites that are rural and urban in providing this coverage. RCW 48.43.735(6) Coverage of telemedicine may be subject to all terms and conditions of the plan, including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance applicable to the service when provided in person. RCW 48.43.735(7) Plan does not have to pay for originating site professional fees; service that is not covered; or an out-of-network originating site or provider. 48.43.735 (8)(a) "Distant site" the site at which a physician or other licensed provider, delivering a professional service, is physically located at the time the service is provided through telemedicine; 48.43.735 (8)(d) "Originating site" the physical location of a patient receiving health care services through telemedicine;
In General Discrimination on the of a health factor prohibited - In General (Cont’d) 45 CFR §146.121(a) (3) 45 CFR §146.117 The decision whether health coverage is elected for an individual (including whether the individual enrolls during special enrollment or late enrollment) is not, itself, within the of any health factor. However, a plan or issuer must treat special enrollees the same as similarly situated individuals who are enrolled when first eligible. Discrimination In Eligibility Rules Prohibited Discrimination on the Basis of a Health Factor Prohibited – 42 U.S.C. §300gg-4 (a) 45 CFR §146.121 (b)(1)(i) Prohibited discrimination in for eligibility: May not have any rule for eligibility (including continued eligibility) of any individual to enroll that discriminates based on any health factor that relates to that individual or a dependent of that individual, subject to the provisions below regarding how this rule applies to benefits, allows establishment of groups of similarly situated individuals, provides for wellness programs, and permits favorable treatment of individuals with adverse health factors. 45 C.F.R. §146.121 Rules for eligibility include, but are not limited to, rules relating to— Enrollment;