Alternative to Hospitalization (Cont’d) Requirement to cover home care in Lieu of Hospitalization (Cont’d) WAC Such substitution must be made only with the consent of the insured and on the recommendation of the insured's attending physician or licensed provider that such services will adequately meet the insured patient's needs. The decision to substitute less expensive or less intensive services shall be determined based on the medical needs of the individual enrollee. WAC HCSC may require that home health agencies or similar alternative care providers have written treatment plans which are approved by the enrollee’s attending physician or other licensed provider. WAC Coverage may be limited to no less than the maximum benefits which would be payable for hospital or other institutional expenses under the contract, and may include all deductibles and coinsurances which would be payable by the insured under the hospital or other institutional expense coverage of the insured's contract. Ambulatory Patient Services (EHB) General Ambulatory Patient Services Requirements 42 USC §18021 (a)(1)(B); 42 USC 18022 (b)(1)(A); WAC 284-43-5642(1) Plan must cover "ambulatory patient services" substantially equal to the base benchmark plan. In determining AV, an issuer must classify as "ambulatory patient services" those medically necessary services delivered to enrollees in settings other than a hospital or skilled nursing facility, which are generally recognized and accepted for diagnostic or therapeutic purposes to treat illness or injury. WAC Plan must cover the following, which are specifically covered by the base benchmark plan, and classify them as ambulatory patient services: Home and outpatient dialysis services; WAC Hospice and home health care, including skilled nursing care as an alternative to hospitalization consistent with state law. 284-43-
Coordination of Benefits (Cont’d) 284-51-205 (4)(b)(i)(A) The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or 284-51-205 (4)(b)(i)(B) If both parents have the same birthday, the plan that has covered the parent longest is the primary plan. WAC 284-51-205 (4)(b)(ii) For a dependent whose parents are divorced or separated or are not living together, whether or not they have ever been married: WAC 284-51-205 (4)(b)(ii)(A) If a court decree states that one parent is responsible for the dependent child's health care expenses or coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with responsibility has no health care coverage for the dependent child's health care expenses, but that parent's spouse does, that parent's spouse's plan is the primary plan. This does not apply to any plan year during which benefits are paid or provided before the plan has actual knowledge of the court decree provision; WAC 284-51-205 (4)(b)(ii)(B) If a court decree states one parent is to assume primary financial responsibility for the dependent child but does not mention responsibility for health care expenses, the plan of the parent assuming financial responsibility is primary; WAC 284-51-205 (4)(b)(ii)(C) If a court decree states that both parents are responsible for the dependent child's health care expenses or coverage, the provisions above for parents married or living together determine the order of benefits; WAC (4)(b)(ii)(D) If a decree states that the parents have joint custody without specifying that one parent has financial responsibility or responsibility for the health care expenses or health care coverage of the dependent child, the above provisions for
(Cont’d) Preexisting Conditions (Cont’d) individual's preexisting health conditions. Plan may not include a waiting period for benefits or enrollment due to a preexisting condition. 45 CFR 148.180 (d)(1) Plan may not impose any preexisting condition exclusion on the of genetic information. 42 U.S.C. §300gg-7 Issuer cannot apply any waiting period longer than 90 days. Resources: 42 U.S.C. Plan must correctly define “Preexisting Condition”. The term “preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or 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. Special Enrollment Periods – Federal law 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). 45 C.F.R. Plan must offer enrollment to eligible persons regardless of open enrollment requirements (“special enrollment”), in the following §300gg-
Every Category of Provider (Cont’d) "Benefits under this contract will not be denied for any health care service performed by a registered nurse licensed to practice under chapter 18.88 RCW, if first, the service performed was within the lawful scope of such nurse's license, and second, this contract would have provided benefits if such service had been performed by a doctor of medicine licensed to practice under chapter 18.71 RCW." WAC 284-44-045(4) The contract may not contain a provision which places restrictions or limitations on benefits for services by nurses or any class of doctors which are not also placed on benefits for services by other doctors. E.g., plan may not limit the number of office calls made to a RN to fewer than the limit for office calls made to a MD. Coverage of Chiropractic care 48.43.190 Plan must chiropractic care on the same basis as other care. RCW 48.44.310 Benefits cannot be denied on the that a service is not performed by a physician licensed under Chapter 18.57 or 18.71 RCW. WAC Must provide direct access to a chiropractor without a referral for covered chiropractic benefits, but can restrict this to in-network chiropractors.
Optional Hospitalization Services (Cont’d) WAC Hospitalization where mental illness is the primary diagnosis to the extent that it is classified under the mental health and substance use disorder benefits category; WAC RCW 48.44.330 Cosmetic or reconstructive services and supplies except in the treatment of a congenital anomaly, to restore a physical bodily function lost as a result of injury or illness, or related to breast reconstruction following a medically necessary mastectomy; WAC The following types of surgery: Bariatric surgery and supplies; WAC Orthognathic surgery and supplies unless due to temporomandibular joint disorder or injury, sleep apnea or congenital anomaly. 5642(3)(b)(iv) Reversal of sterilizations; and WAC Surgical procedures to correct refractive errors, astigmatism or reversals or revisions of surgical procedures which alter the refractive character of the eye.
Hospitalization (EHB) (Cont’d) Classified to the Hospitalization Category RCW ; IF a plan covers care in a long term care facility, carrier must allow enrollee to return to the same long term care facility after hospitalization, as long as the following criteria are met (WAC 284-43-5642(3)(e)(iv)): (Cont’d) RCW 48.13.125 (1)(a) The person's primary care physician determines that the medical care needs of the person can be met at the requested facility; RCW 48.43.125 (1)(b) The requested facility has all applicable licenses and certifications, and is not under a stop placement order that prevents the person's readmission; RCW 48.43.125 (1)(c) The requested facility agrees to accept payment from the carrier for covered services at the rate paid to similar facilities that otherwise contract with the carrier to provide such services; and RCW 48.43.125 (1)(d) The requested facility, with regard to the following, agrees to abide by the standards, terms, and conditions required by the carrier of similar facilities with which the carrier otherwise contracts: (i) Utilization review, quality assurance, and peer review; and (ii) management and administrative procedures, including data and financial reporting that may be required by the carrier.
Dependent Daughter Coverage WAC 284-43-5602 Plan must include maternity coverage and newborn delivery for dependent daughters on the same basis as the EHB-benchmark plan. Religious Exception 45 CFR §147.131(b) An employer is an “eligible organization” to obtain a religious exemption from providing contraceptive coverage if it: Religious Exception to 45 CFR §147.131(b)(1) Has religious objections to providing coverage for some or all contraceptive items or services; AND Providing Contraception Coverage – 45 CFR §147.131 (b)(2)(i) Either Is organized and operates as a nonprofit entity and itself out as a religious organization; OR Eligible Organization (b)(2)(ii) Is organized and operates as a closely held for-profit entity, and the organization's highest governing body has adopted a resolution or similar action establishing that it objects to covering some or all of the contraceptive services on account of the owners' sincerely held religious beliefs; AND 45 CFR §147.131 (b)(3) Has either self-certified as such to the Secretary of Labor, or has provided notice of such to the Secretary of Health and Human Services. 45 CFR §147.131 (c)(1) The carrier must have received either a copy of the from the issuer, or notice from the Department of Labor, demonstrating that the employer is an eligible organization. Religious Exemption to Providing Contraception 45 CFR §147.131 (c)(2)(i)(B) The carrier must provide separate payments for any contraceptive services required to be covered under §147.130(a)(1)(iv) for plan participants and beneficiaries for so long as they remain enrolled in the plan. self-
Pediatric Vision Services (EHB) Pediatric Vision Services (EHB) (Cont’d) (3)(b) Ordering two pairs of glasses in lieu of bifocals. Requirement to Cover RCW 48.44.440 Plan must provide coverage for the formulas necessary for the treatment of phenylketonuria. WAC 284-44-450(2).
(Cont’d) Drug Exception / Substitution Process (Cont’d) 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
Prescription Drugs (Cont’d) Preventive and Wellness Services, Including Chronic Disease Management (EHB) Preventive and Wellness Services, Including Chronic Disease Management (EHB) (Cont’d) Definition of Preventive and Wellness Services, Including Chronic Disease Management 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 base benchmark 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 for Preventive and Wellness Services WAC WAC 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 with respect to the item or service. WAC Plan must not limit sex-specific recommended preventive services based on an individual's sex assigned at birth, gender identity or recorded gender. If a provider determines that a sex-specific recommended preventive service is medically appropriate for an individual, and the individual otherwise satisfies the coverage requirements, the plan must provide coverage without cost-sharing.
Preventive and Wellness Services, Including Chronic Disease Management (EHB) (Cont’d) Requirements for Preventive and Wellness Services (Cont’d) 5642(9)(b)(vi) Wellness services. Prohibited Limitations on Preventive WAC Plan may not include cost sharing requirements with respect to the preventive services listed under WAC 284-43-5642(9) (b)(i) through (iv) that are provided in-network.
Preventive and Wellness Services, Including Chronic Disease Management (EHB) (Cont’d) RCW 48.44.212; WAC Treatment of congenital anomalies in newborn and dependent children. This state benefit requirement may be classified to hospitalization, ambulatory patient services or maternity and newborn categories.
Allowable Limitations on Rehabilitative and Habilitative Services WAC Inpatient rehabilitation facilities and professional services delivered in those facilities may be limited to no less than thirty service days per calendar year; and WAC Outpatient physical therapy, occupational therapy and speech therapy may be limited to no less than twenty-five outpatient visits per calendar year, on a combined for rehabilitative purposes. State Benefit Requirements WAC State benefit requirements classified to this category include: State sales tax for durable medical equipment; and RCW 48.44.315 Coverage of diabetic supplies and equipment. WAC
Rehabilitative and Habilitative Services (EHB) (Cont’d) Subrogation Thiringer v. American Motors Ins., 91 WN 2d 215, 588 P.2d 191 (1978) If the contract includes a subrogation provision, it must: • Make clear that the issuer is entitled only to excess after the enrollee is fully compensated; and • The Contract must not have any provision which would inappropriately require full reimbursement for all medical expenses. WAC The contract cannot unreasonably restrict or delay the payment of benefits. Delays are not justified because the expenses incurred, or
(b)(1)(ii)(B) The effective date of coverage; (b)(1)(ii)(C) Waiting (or affiliation) periods; (b)(1)(ii)(D) Late and special enrollment; (b)(1)(ii)(E) Eligibility for benefit packages (including rules for individuals to change their selection among benefit packages); (b)(1)(ii)(F) Benefits (including rules relating to covered benefits, benefit restrictions, and cost-sharing) (b)(1)(ii)(G) Continued eligibility; and (b)(1)(ii)(H) Terminating coverage (including disenrollment) of any individual. 45 CFR 148.180(b)(1) Plan may not establish rules for the eligibility (including continued eligibility) of any individual to enroll based on genetic information. In Benefits Discrimination on the Basis of a Health Factor Prohibited – In Benefits (Cont’d) 45 CFR §146.121 (b)(2)(i)(A) Prohibited discrimination in benefits: General rule: Issuer is not required to provide coverage for any particular benefit to any group of similarly situated individuals. (b)(2)(i)(B) However, benefits that are provided must be uniformly available to all similarly situated individuals. 45 CFR §146.121 (b)(2)(i)(B) Any restriction on a benefit must apply uniformly to all similarly situated individuals. Must not be directed at individual participants based on any health factor. Issuer may limit or exclude benefits in relation to a specific disease or condition, limit or exclude benefits for certain types of treatments or drugs, or limit or exclude benefits based on a determination of whether the benefits are experimental or not medically necessary, but only if the benefit limitation or exclusion applies uniformly to all similarly situated individuals and is not directed at individual participants based on any health factor of the participants.
Unfair and Discriminatory Practices (Cont’d) “Source of Injury” “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.