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. Appeals Procedures (Cont’d) Internal Appeals under Health Plans (Cont’d) 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. 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. WAC An enrollee or the enrollee's representative, including the treating provider (regardless of whether the provider is contracted with the issuer) acting on behalf of the enrollee may appeal an adverse determination in writing. The issuer must reconsider the adverse determination and notify the enrollee of its decision within fourteen days of receipt of the appeal.
WAC (4)(e) "Life threatening condition" means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted. Colorectal Cancer Screening Colorectal Cancer Screening (Cont’d) Requirement for Coverage RCW 48.43.043(1) Plan must provide coverage for colorectal cancer exams and lab tests consistent with the A and B recommendations of the USPSTF or the CDC. Coverage must be provided: Requirement for Coverage (Cont’d) RCW 48.43.043 (1)(a) RCW 48.43.043 (1)(b)(i) For any of the colorectal screening exams and tests in the selected recommendations, at a frequency identified therein, as deemed appropriate by the patient's physician after consultation with the patient; and To an enrollee who is: 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.
Thiringer v. American \Motors Ins contract. Delays are not justified because the expenses incurred, or the services received, resulted from an act or omission of a third party. Payment Grace Period Required RCW 48.20.062 There must be a provision as follows: PERIOD: A grace period of . . . . (insert a number not less than "7" for weekly premium policies, "10" for monthly premium policies, and "31" for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force. (A policy contains a cancellation provision may add, at the end of the above provision: "subject to the right of the insurer to cancel in accordance with the cancellation provision hereof." A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision: "Unless not less than five days prior to the premium due date the insurer has delivered to the insured or has mailed to his or her last address as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted." No Retrospective denials RCW 48.43.525(1) Plan must not 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. RCW 48.20.525 When an authorized plan representative approves a claim for an individual prescription, the plan may not later reject that claim. Cost Sharing Requirement WAC Plan must not apply cost-sharing requirements to Native Americans purchasing a health benefit plan through the
Guaranteed Issue and Continuity of Coverage Guaranteed Issue and Continuity of Coverage (Cont’d) Issuer Must Accept All Residents in Service Area 45 CFR §147.104(a) Issuer must accept for enrollment any state resident within the group to whom the plan is offered and within the carrier's service area and provide or assure the provision of all covered services regardless of age, sex, family structure, ethnicity, race, religion, national origin, health condition, geographic location, employment status socioeconomic status, the presence of any sensory, mental, or physical handicap, other condition or situation, or actual or perceived status regarding HIV or Hepatitis C. Contract Must Contain Guarantee of Continuity 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. When Plan May Be Nonrenewed 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; RCW 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;
Treatment (EHB) (Cont’d) 2008 (“MHPAEA”)) RCW 48.20.580 (2)(a) 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 48.20.580 (2)(a) If the plan has a maximum out-of-pocket limit or stop loss, it must be for medical, surgical, and mental health - it cannot have a separate MOOP or stop loss for mental health. 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 48.20.580 (2)(b) 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 48.20.580(4) Health benefit plans may not reduce the number of mental health outpatient visits or mental health inpatient days below the level in effect on July 1, 2002. WAC Plan must cover MH/SUD benefits in every classification in which medical/surgical benefits are provided. WAC &(6)(a)(i)(ii) 6 Classifications: Inpatient, in-network; inpatient, outpatient, in-network; outpatient, out-of-network; emergency care; and prescription drugs. Outpatient services may be subclassified into office visits and all other outpatient items and services. WAC In determining the classification in which a particular benefit belongs, a plan must apply the same standards to
Required Services (Cont’d) (2)(f)(iii) Follow-up care of four visits in any five-year period, with approval. Allowed Exclusions WAC The plan may include the following exclusions: Visual therapy that is otherwise covered the medical/surgical benefits of the plan; and
Pediatric Vision Services (EHB) (Cont’d) PKU Phenylketonuria Formula RCW 48.20.520; WAC Plan must provide coverage for the formulas necessary for the treatment of phenylketonuria Prescription Drug Services (EHB) Prescription Drug Services (EHB) Required Prescription Drug Services Required Prescription 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 (6)(a)(i) Plan must include the following services, which are specifically covered by the base-benchmark plan, and classify them as prescription drug services:
Prescription Drug Services (EHB) (Cont’d) Pharmacists – Eye Drop Refills Pharmacists – Eye Drop Refills (Cont’d) RCW 18.64.530(3) The refill does not exceed the number of refills that the prescriber indicated.
Prior Authorization (Cont’d) 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 Provider Requirements (Cont’d) Access to Primary Care Providers Access to Primary Care Providers (Cont’d) 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) RCW 48.43.515(2) Plan must allow enrollees to change primary care providers at any time with the change becoming effective no later than the beginning of the month following the enrollee's request for the change. WAC 284-170-360(1)(a) WAC Plan must an enrolled child direct access to a pediatrician from a list of in-network pediatricians who are accepting new patients. WAC Plan must allow enrollees to change pediatricians at any time, with the change becoming effective not later than the beginning of the month following the enrollee's request for the change.