Services (EHB) (Cont’d) Benefit Requirements Classified to WAC Plan must include the following benefit requirements classified to the ambulatory patient services category: Chiropractic care; Ambulatory Services RCW 48.44.315 TMJ disorder treatment (WAC 284-43-5642(1)(d)(ii)); and Category WAC Diabetes-related care and supplies (RCW , , and ). Appeals Procedures Resources: ; Internal appeals / review of adverse benefit decisions under Both Grand-fathered 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? WAC The issuer’s process for review of adverse benefit determinations must meet accepted national certification standards such as used by the National Committee for Quality Assurance, except as otherwise required under Chapter 284-43 WAC. RCW 48.43.530 (8) WAC 284-43-3050 WAC 284-43-4020(2)(a) Does the contract provide a clear explanation of the appeal / review of adverse benefit determination process? Appeals Procedures (Cont’d) Internal appeals / review of adverse benefit decisions under Both Grand- RCW 48.43.530(9) WAC WAC The process must be accessible to enrollees who are limited English speakers, who have literacy problems, or who have physical or mental disabilities that impede fathered Non-Grand-
Appeals Procedures (Cont’d) Internal Appeals under Health Plan (Cont’d) RCW 48.43.530(5)(b) WAC WAC The issuer must assist the enrollee with the appeal process. RCW 48.43.530(5)(d) WAC The issuer must cooperate with any representative authorized in writing by the enrollee. RCW 48.43.530(5)(e) WAC WAC The issuer must consider all information submitted by the enrollee or representative. RCW 48.43.530(5)(f) WAC The issuer must investigate and resolve all appeals / requests for review of adverse benefit determination. RCW 48.43.530(4)(a) The review of a decision to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services or benefits, including admission to, or continued stay in, a health care facility, is processed as an appeal. Appeals Procedures (Cont’d) Internal Appeals under Health Plans (Cont’d) WAC The issuer must: respond to oral and written appeals in a timely and thorough manner; notify the enrollee that an appeal has been received. Grand- fathered
(1)(b)(i) At least fifty years old; or RCW 48.43.043 (1)(b)(ii) Less than fifty years old and at high risk or very high risk for colorectal cancer according to such guidelines or recommendations. Burdensome Requirements Prohibited RCW 48.43.043(2) Plan design must not require patients and providers to meet burdensome criteria or overcome significant obstacles to secure such coverage. Enrollee may not be required to pay an additional deductible or coinsurance for testing greater than a deductible or coinsurance for similar benefits. If the plan does not cover a similar benefit, a deductible or coinsurance may not be set that materially diminishes the value of the colorectal cancer benefit required. If no provider available RCW 48.43.043(3)(a) Issuer is not required to provide for referral to an out-of-network provider, unless the carrier does not have an in-network provider that is appropriate, available and accessible to administer the screening exam. RCW 48.43.043(3)(b) If issuer has no appropriate in-network provider, then screening exam services and resulting treatment, if any, must be provided at no additional cost to the enrollee beyond what he/she would pay for in-network services. Congenital Abnormalities Requirement for Coverage RCW 48.44.212(1) If plan provides coverage for dependent children of the enrollee, must provide coverage for newborn infants of the enrollee from and the moment of birth. Coverage must include, but not be limited to, coverage for congenital anomalies of such infant children from the moment of birth. RCW 48.44.212(2) If payment of an additional premium is required to provide coverage for a child, the contract may require that notification of
Coordination of Benefits (Cont’d) General (Cont’d) (4)(c) o A person could have elected an option under another plan that pays a higher level of benefits than what he elected. WAC • Plan may not provide that its benefits are "always excess" or "always secondary" except as permitted in Chapter 284-51 WAC. RCW 48.21.200(1) • A carrier may not administer COB in a way that reduces benefits payable below an amount equal to 100% of total allowable expenses. (Note: by its terms, this statute applies to HCSCs) WAC 284-51-230(1) • Any secondary plan must pay an amount which, together with the payment made by the primary plan, cannot be less than the same allowable expense as the secondary plan would have paid if it was the primary plan. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. WAC 284-51-195(1) • When Medicare, Part A, Part B, Part C, or Part D is primary, Medicare's allowable amount is the allowable expense. Time Limit WAC 284-51-215(1) Plan must not unreasonably delay payment of a claim due to a COB provision. Any time limit in excess of 30 days is unreasonable. Definition of “Plan” WAC 284-51-195(12) "Plan" means coverage with which coordination is allowed. Separate parts of a plan provided through alternative contracts intended to be part of a coordinated package of benefits are considered one plan. There is no COB among the separate parts of the plan.
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.
Dependent Enrollment Requirements Dependent Enrollment Requirements (Cont’d) Newborn Coverage (“Erin Act”) RCW 48.43.115(3)(f) Coverage for newborns must be no less than the coverage of the child's mother for no less than three weeks (21 days), even if there are separate hospital admissions. Adoptive Child RCW 48.01.180 (1) A child must be considered a dependent child for coverage purposes upon assumption of a legal obligation for total or partial support of a child in anticipation of adoption. On termination of such legal obligations, the child shall no longer be considered a dependent child for coverage purposes. RCW 48.01.180 (2); RCW 48.44.420(1) Coverage for dependent children placed for adoption must be provided under the same terms and conditions as apply to natural, dependent children, whether or not the adoption has become final. RCW 48.01.180 (3) Contract may not restrict coverage of any dependent child adopted by, or placed for adoption with, an enrollee solely on the basis of a preexisting condition of the child at the time that the child would otherwise become eligible for coverage under the plan if the adoption or placement for adoption occurs while the enrollee is eligible for coverage under the plan. RCW 48.44.420(2) If payment of an additional premium is required to provide coverage for the the contract may require notification of placement and payment of the required premium. The notification period shall be no less than sixty days from the date of placement. Disabled Child Over Age Limit RCW 48.44.200 If the contract states that coverage of a dependent child will terminate upon attainment of the limiting age for dependent children, the contract must also state that coverage of a dependent child will not be terminated while the child is and continues to be both (1) incapable of self-sustaining employment
Emergency Services (EHB) (Cont’d) RCW 48.43.093; WAC Plan must include the services necessary to screen and stabilize a covered person, classified to the emergency medical services category. WAC If plan restricts treatment to services by in-network providers, must include a reasonable provision to allow emergency treatment consistent with the scope of the benefits regularly provided by the contract. WAC Enrollees must have access to emergency services twenty-four hours per day, seven days per week. Definition of “Emergency Services” 42 U.S.C. §300gg-19a (b) (2)(B); RCW 48.43.005 (14) Plan’s definition of "Emergency services" must be 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))”. Definition of “Emergency Medical Condition” 42 U.S.C. RCW 48.43.005(13) Plan’s definition of "Emergency medical condition" must be consistent with RCW 48.43.005(13), or WAC 284-43-130(6) which states: “’Emergency Medical Condition’ means the emergent and acute onset of a symptom or symptoms, including severe pain, that
Emergency Services (EHB) (Cont’d) Prescription Drugs WAC Plan must cover prescription medications associated with an emergency medical condition including those purchased in a foreign country. Every Category of Provider Requirements 42 U.S.C. §300gg-5(a) See Plan and Issuer must not discriminate with respect to participation under 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 284-170-200(2); WAC 284-170-270(1) WAC Each health plan’s defined service area must have a comprehensive range of primary, specialty, institutional, and ancillary services available without unreasonable delay to all
Every Category of Provider (Cont’d) Experimental or Investigational Treatment WAC If the contract includes exclusion, reduction or limitation for services that are experimental or investigational, contract must include a definition of Experimental and Investigational services. WAC 284-44-043 (2) The definition must include an identification of the authority or authorities which will make a determination of
Laboratory Services (EHB) (Cont’d) Optional Laboratory Services WAC Plan may, but is not required to, include procurement and storage of personal blood supplies provided by a member of the enrollee's family when this service is not medically indicated. If an issuer includes this benefit in a health plan, the issuer may not include this benefit in establishing the health plan's actuarial value. Maternity and Newborn Services (EHB) Maternity and Newborn Services (EHB) (Cont’d) Requirement to cover 42 USC §18021 (a)(1)(B) 42 USC 18022(b)(1)(D) Plan must cover "maternity and newborn 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 maternity and newborn services the medically necessary care and services delivered to women during pregnancy and in relation to delivery and recovery from delivery and to newborn children. WAC 284-43-5642(4) Required Maternity and Newborn Services Required Services (Cont’d) WAC Plan must cover the following services which are specifically covered by the base-benchmark plan and classify them as maternity and newborn services: In utero treatment for the fetus; WAC Vaginal or cesarean childbirth delivery in a hospital or birthing center, including facility fees; WAC Nursery services and supplies for newborns, including newly adopted children; (4)(a)(iv) Infertility diagnosis; (4)(a)(v) Prenatal and postnatal care and services, including screening;
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 requirements for Maternity and Newborn Services State benefit requirements for Maternity 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) Must provide newborn coverage that is not less than the postnatal coverage for the mother, for no less than three weeks (WAC 284-43-5642(4)(d)(ii)); and RCW 48.44.344 Prenatal diagnosis of congenital disorders by screening/diagnostic procedures if medically necessary. WAC 284-43-5642(4)(d)(iii)
Prescription (Cont’d) Pharmacists – Eye Drop Refills RCW 18.64.530 Forms may not include any provision conflicting with the following: A pharmacist is authorized, without consulting a physician or obtaining a new prescription or refill authorization from a physician, to provide for one early refill of a prescription for topical ophthalmic products if: RCW 18.64.530(1) • The refill is requested by a patient at or after seventy percent of the predicted days of use of RCW 18.64.530(1)(a) The date the original prescription was dispensed to the patient; or RCW 18.64.530(1)(b) The date that the last refill of the prescription was dispensed to the patient;
or subcontracting arrangement for its prior authorization program. Prior Authorization WAC A prior authorization program must meet standards set forth by a national accreditation organization including, but not limited to, National Committee for Quality Assurance (NCQA), URAC, Joint Commission, and Accreditation Association for Ambulatory Health Care in addition to the requirements of and . A prior authorization program must have staff who are properly qualified, trained, supervised, and supported by explicit written, current clinical review criteria and review procedures. Transparency of Standards and Criteria RCW 48.43.016(1) If the plan imposes different authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession, the contract must inform enrollees which tier an individual provider or group of providers is in by posting the information on its web site in a manner accessible to both enrollees and providers. RCW 48.43.016(3) Plan must post on its web site and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions. Prohibited Practices RCW 48.43.016(2) Plan may not require authorization for an initial evaluation and management visit and up to six consecutive treatment visits with a contracted provider in a new episode of care of chiropractic, physical therapy, occupational therapy, East Asian
medicine, massage therapy, or speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan. Plan may require a referral or prescription for these therapies, other than chiropractic. RCW 48.43.515(5) RCW 48.43.016 (6)(a) "New episode of care" treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment. Prior Authorization (Cont’d) Prohibited Practices (Cont’d) RCW 48.43.016 (6)(b) "Contracting provider" does not include providers employed within an integrated delivery system operated by an HCSC. Issuer must Consult with Licensed Provider in Field Being Reviewed RCW 48.43.016(4) Any provider with whom the issuer consults regarding a decision to deny, limit, or terminate covered services must hold a license, certification, or registration, in good standing and must be in the same or related health field as the provider being reviewed or of a specialty which entails the same or similar covered health care service. No Required Discounts RCW 48.43.016(5) Issuer may not require a provider to provide a discount from and customary rates for health care services not covered under a health plan, policy, or other agreement, to which the provider is a party. Provider Requirements Access to PCPs RCW 48.43.515(2); Plan must allow enrollee to choose a primary care provider who is accepting new enrollees from a list of participating providers. WAC 284-170-360(1)
Rehabilitative and Habilitative Services (EHB) (Cont’d) Required Rehabilitative and Habilitative Services (EHB) (Cont’d) WAC Inpatient rehabilitation facilities and professional services delivered in those facilities; WAC Outpatient physical therapy, occupational therapy and speech therapy for rehabilitative purposes; WAC Braces, splints, prostheses, orthopedic appliances and orthotic devices, supplies or apparatus used to support, align or correct deformities or to improve the function of moving parts; and 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: Off-the-shelf 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 other than cochlear implants. Habilitative Services Definition WAC For purposes of determining a plan's AV, issuer must classify as habilitative services the range 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
Rules for “Originating Sites” (Cont’d) 48.43.735 (8)(d) "Originating site" means the physical location of a patient receiving health care services through telemedicine; and Forward Technology” Definition 48.43.735(8)(f) and forward technology" means use of an asynchronous transmission of a covered person's medical information from an originating site to the health care provider at a distant site which results in medical diagnosis and management of the covered person, and does not include the use of audio-only telephone, facsimile, or email. Transgender Services 42 USC §18116; RCW 48.30.300; Chapter 49.60 RCW exclusions of coverage, and denial of a medically necessary service, on the basis of gender identity are prohibited. This prohibition applies in the issuance, cancellation, or renewal of any contract of insurance, as well as amount of benefits payable, or any term, rate, condition, or type of coverage offered. A plan may
Unfair and Discriminatory Practices (Cont’d) In Rules for Eligibility (Cont’d) (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. Discrimination on the Basis of a Health Factor Prohibited- In Benefits Discrimination on the of a Health Factor Prohibited – 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
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.