Ambulatory Patient Services (EHB) (Cont’d) Applications Carrier must Submit Application to be Used for Direct Sale of Plans 45 CFR 147.104(a) The federal statutory guaranteed issue requirement and implementing rule do not distinguish between exchange and non-exchange products and do not except plans from the requirement that all products approved for sale in the individual market must be made available to any individual who applies for any of those products inside or outside the exchange. Carriers must submit an application to be used for the direct sale of Exchange-only products outside of the Exchange when requested.
WAC Items and services that are not used in the direct clinical management of the enrollee; or The investigational item, device, or service itself. WAC WAC “Clinical trial” means a phase I, II, III, or IV clinical conducted in relation to the prevention, detection, or treatment of cancer or other disease or condition, funded or approved by: One of the National Institutes of Health (NIH); WAC WAC An NIH cooperative group or center which is a formal network of facilities that collaborate on research projects and have an established NIH-approved peer review program including, but not limited to, the NCI Clinical Cooperative Group and the NCI Community Clinical Oncology Program; The federal Departments of Veterans Affairs or Defense; WAC An institutional review board of an institution in this state that has a multiple project assurance contract approval by the Office of Protection for the Research Risks of the NIH; or WAC A qualified research entity that the criteria for NIH Center Support Grant eligibility. threatening
Coordination of Benefits (Cont’d) Rules for Coordination of Benefits Rules for Coordination of Benefits (Cont’d) WAC If none of the preceding rules determines the order of benefits, the allowable expenses must be shared equally between the plans.
Rules for Coordination of Benefits (Cont’d) Rules for Secondary Plan Payment Rules for Secondary WAC In determining the amount to be paid by the secondary plan if the plan wishes to coordinate benefits, the secondary plan must pay an amount that, when combined with the amount paid by the primary plan, the total benefits paid by all plans equal one hundred percent of the total allowable expense for that claim. The secondary carrier must not be required to pay an amount in excess of its maximum benefit plus accrued savings. The enrollee must not be responsible for a deductible amount greater than the highest of the two deductibles. WAC “Gatekeeper requirements” any requirement that an otherwise eligible person must fulfill prior to receiving the benefits of a plan. (e.g, use of network providers, prior authorization, primary care physician referrals, or other similar case management requirements.) If a plan by its terms contains gatekeeper requirements, AND a person fails to comply with such requirements, And an alternative procedure is not agreed upon between both plans and the covered person: WAC If the plan is secondary, all secondary gatekeeper requirements will be waived if the gatekeeper requirements of the primary plan have been met. WAC If the primary plan becomes secondary during a course of treatment, the new primary plan must make reasonable provision for continuity of care if one or more treating providers are not in the new primary plan's network. WAC 284-51-230(4) When a plan is secondary, it may reduce its benefits so the total benefits provided by all plans during a claim determination period do not exceed
Eligibility (Cont’d) Emergency Medical Services (EHB) Emergency Medical Services (EHB) (Cont’d) Required Emergency Services 42 USC §18021(a)(1)(B) and (b)(1)(B) Plan must cover “emergency medical services" in a manner substantially equal to the base-benchmark plan. For purposes of determining a plan's actuarial value, an issuer must classify as emergency medical services the care and services related to an emergency medical condition. WAC Required Emergency Services (Cont’d) WAC Plan must include the following services which are specifically covered by the base-benchmark plan and classify them as emergency services: WAC Ambulance transportation to an emergency room and treatment provided as part of the ambulance service; WAC Emergency room and department services, supplies and treatment, including professional charges, facility costs, and outpatient charges for patient observation and medical screening 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. RCW 48.43.093; WAC WAC Plan must include the services necessary to screen and stabilize a covered person, classified to the emergency medical services category. 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. Required Emergency Services (Cont’d)
Emergency Medical Services (EHB) (Cont’d) layperson acting reasonably would have believed that an emergency medical condition existed. RCW 48.43.093 (1)(a); 42 U.S.C. The plan must cover out-of-network emergency services necessary to screen and stabilize a covered person if a prudent layperson would have reasonably believed that use of an in-network emergency department would result in a delay that would worsen the emergency, or if a provision of federal, state, or local law requires the use of a specific provider or facility. 45 C.F.R. 147.138(b)(2) (ii) The issuer must not require prior authorization of emergency services provided prior to the point of stabilization if a prudent layperson acting reasonably would have believed that an emergency medical condition existed and that use of an in-network emergency department would result in a delay that would worsen the emergency. 42 Emergency out-of-network coverage must be consistent with scope of regular contract benefits. RCW 48.43.093 (1)(c) Coverage of emergency services may be subject to applicable copayments, coinsurance, and deductibles, and an issuer may impose reasonable differential cost-sharing arrangements for out-of-network emergency services, if such differential between in-network and cost-sharing does not exceed dollars. RCW 48.43.093 (1)(c) Differential cost sharing for out-of-network emergency services beyond evaluation and stabilization may not be applied if: Due to circumstances beyond the enrollee’s control, the enrollee was unable to go to an in-network emergency department in a timely fashion without serious impairment to their health; or A prudent layperson possessing an average knowledge of health and medicine have reasonably believed that they would be unable to go to an in-network emergency department in a timely fashion
Required Terms of Emergency Coverage (Cont’d) without serious impairment to their health. 45 CFR §147.138(b)(3) (i) In addition to the in-network cost-sharing, plan can balance bill individual for the excess of out-of-network provider charges, over the minimum amount the plan is required to pay (see 45 CFR §147.138(b) (3)(i)(A-C) Plan complies with the above cost-sharing requirements for emergency services if it provides coverage at the level of the greatest of these three amounts: (1) the median in-network 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. RCW 48.43.093 (2) For inpatient admission, the issuer may require notification within a specified time frame or as soon thereafter as medically possible, but no less than twenty-four hours. RCW 48.43.093 (1)(d) The issuer must have someone available 24/7 for preauth of or post-stabilization services RCW 48.43.093 (2) The issuer may reserve the right to require transfer of a hospitalized enrollee upon stabilization. network
Every Category of Provider (Cont’d) Coverage of Podiatry RCW 48.46.565 Issuer may not refuse to pay for covered services solely because the services were provided by a Podiatrist or Podiatric Surgeon.
presence of any sensory, mental, or physical handicap, other condition or situation, or actual or perceived status regarding HIV or Hepatitis C. When Plan May Be Nonrenewed RCW 48.43.038(1) 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 which, at the carrier's sole option, the plan could have been terminated for other than nonpayment of premium. RCW 48.43.038 (2)(a) Plan may still be canceled or nonrenewed for: Nonpayment of premium; RCW 48.43.038(2)(b) Violation of published policies of the carrier approved by the commissioner; RCW 48.43.038 (2)(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; 48.43.038 (2)(d) Covered persons who fail to pay any deductible or copayment amount owed to the carrier and not the provider of health care services; (2)(e) Covered persons committing fraudulent acts as to the carrier; (2)(f) Covered persons who materially breach the health plan; or 48.43.038 (2)(g) Change or implementation of federal or state laws that no longer permit the continued offering of such coverage. Guaranteed Renewability Not Required When RCW 48.43.038 (3)(a) Guaranteed renewability is not required where: An issuer has zero enrollment on a product; 48.43.038 (3)(b) An issuer withdraws from part or all of a service area due to demonstrated lack of clinical, financial, or administrative capacity; RCW 48.43.038 (3)(c) Issuer provides a 90 day discontinuation notice to each enrollee, offers each the option to enroll in any of the issuer’s other individual
Hospitalization (EHB) (Cont’d) 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 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. Laboratory Services (EHB) Required Laboratory Services 42 USC §18021 (a)(1)(B) 42 USC 18022 (b)(1)(H); WAC 284-43-5642(8) Plan must cover "laboratory services" in a manner substantially equal to the base-benchmark plan. For purposes of determining actuarial value, an issuer must classify as laboratory services the medically necessary laboratory services and testing, including those performed by a licensed provider to determine differential diagnoses, conditions, outcomes and treatment, and including blood and blood services, storage and procurement, and ultrasound, X ray, MRI, CAT scan and PET scans.
Women’s Direct Access (Cont’d) WAC Plan may not impose cost-sharing for directly accessed women's health care services that is not required for access to primary care providers. State benefit requirement for Maternity and Newborn Services State benefit requirement for Maternity and Newborn Services RCW 48.43.041; WAC Maternity services must include diagnosis of pregnancy, prenatal care, delivery, care for complications of pregnancy, physician services, and hospital services RCW 48.43.115 (3)(f); WAC Must provide newborn coverage that is not less than the postnatal coverage for the mother, for no less than three weeks; and RCW 48.46.375; WAC Prenatal diagnosis of congenital disorders by screening/diagnostic procedures if medically necessary. RCW 48.43.115 (3)(a) Plan must permit the attending provider, in consultation with the mother, to make decisions on the length of inpatient stay. decisions must be based on accepted medical practice. RCW 48.43.115 (3)(b) Plan may not deny covered, eligible services for inpatient, postdelivery care to a mother and her newly born child after a vaginal delivery or a cesarean section delivery that is ordered by the attending provider in consultation with the mother. RCW 48.43.115(3) (c) At the time of discharge, determination of the type and location of follow-up care must be made by the attending provider in consultation with the mother rather than by contract or agreement between the hospital and the insurer. These decisions must be based on accepted medical practice. RCW 48.43.115(3) Plan may not deny covered, eligible services for follow-up care, including in-person care, as ordered by the attending provider in consultation with
(Cont’d) (d) the mother. Coverage for providers of follow-up services must include, but need not be limited to, attending providers, home health agencies licensed chapter RCW, and registered nurses licensed under chapter RCW. RCW 48.43.115(3)(e) This section does not require attending providers to authorize care they believe to be medically unnecessary. Length of Stay RCW 48.43.115(3) (“Erin Act”); PHSA 2704 (“Newborns’ and Mothers’ Health Protection Act of 1996”) The plan must provide notice that the health care provider in consultation with the mother will determine the care and length of hospital stay. If length of stay guideline is stated it must be no less than: normal caesarian section birth. The plan cannot restrict follow-up care when ordered by the attending provider in consultation with the mother.
WAC Premium charged must be no greater as a result of a family or individual receiving PKU benefits. Prescription Drug Services (EHB) Prescription Drug Services (EHB) (Cont’d) Required Prescription Drug Services Required Prescription Drug Services (Cont’d) 42 USC §18021 (a)(1)(B); 42 USC 18022(b)(1)(F) Plan must cover "prescription drug services" in a manner substantially equal to the base-benchmark plan. For purposes of determining a plan's actuarial value, an issuer must classify as prescription drug services medically necessary prescribed drugs, medication and drug therapies. WAC 284-43-5642(6) WAC Plan must include the following services, which are specifically covered by the base-benchmark plan, and classify them as prescription drug services: Drugs and medications both generic and brand name, including prescription medications, WAC Prescribed medical supplies, including diabetic supplies that are not otherwise covered as durable medical equipment under the rehabilitative and habilitative services category, including test strips, glucagon emergency kits, insulin and insulin syringes; WAC All FDA-approved contraceptive methods, and prescription-based sterilization procedures for women with reproductive capacity WAC "Prescription contraceptives" include United States Food and Drug Administration (FDA) approved contraceptive drugs, devices, and prescription barrier methods, including contraceptive products declared safe and effective for use as emergency contraception by the FDA.); WAC Plan must not cover prescription contraceptives on a less favorable basis than other covered prescription drugs and prescription devices. Coverage of prescription contraceptives includes coverage for medical services associated with the prescribing, dispensing, delivery, distribution, administration and removal of a prescription self-
Prescription Drug Services (EHB) (Cont’d) Prescription RCW 48.43.096(1) Issuer must have a prescription synchronization/coordination policy for the dispensing of prescription drugs to the plan's enrollees. 48.43.096 (1)(a) 48.43.096 (1)(a)(i) (1)(a)(ii) If an enrollee requests medication synchronization for a new prescription, the health plan must permit filling the drug: o for less than a one-month supply of the drug if synchronization will require more than a fifteen-day supply of the drug; or o for more than a one-month supply of the drug if synchronization will require a fifteen-day supply of the drug or less. 48.43.096 (1)(b) The health benefit plan adjust the enrollee cost-sharing for a prescription drug subject to coinsurance that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications. 48.43.096 (1)(c) The health benefit plan adjust the enrollee cost-sharing for a prescription drug with a copayment that is dispensed for less than the standard refill amount for the purpose of synchronizing the medications by: Discounting the copayment rate by fifty percent; Discounting the copayment rate based on fifteen-day increments; or Any other method that meets the intent of this section and is approved by the OIC. Note: In order to have an alternative method approved by OIC, the issuer should submit a request for approval to the Manager of the Health & Disability Forms Unit. The request may be sent by any means, including being submitted on the Supporting Documentation tab as part of the filing seeking to utilize the method. The request must include complete information regarding the proposed alternative method. If the plan utilizes an alternative method that has already been approved by the OIC, the filing should include this information in
Requirements for Preventive and Wellness Services (Cont’d) (9)(b)(vi) Wellness services. Prohibited Limitations on Preventive and Wellness Services 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.) State 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 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. WAC
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.
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" means the physical location of a patient receiving health care services through telemedicine;
Discrimination on the basis of a health factor prohibited In General 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 scope 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 of 42 U.S.C. §300gg-4 (a) 45 CFR §146.121 (b)(1)(i) Prohibited discrimination in rules 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,