Ambulatory Patient Services (EHB) Appeal Procedures Resources: ; Internal appeals/ review of adverse benefit decisions under Both Grand-fathered 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 operational, comprehensive process for review of appeals / adverse benefit determinations?
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. Appeals Procedures (Cont’d) Expedited Internal Reviews of Adverse Benefit Determinations under Fathered Plans (Cont’d) RCW 48.43.530(5)(c) WAC The issuer must respond as expeditiously as possible to an expedited review request, preferably within twenty-four hours, but in no case longer than seventy-two hours. The decision regarding an expedited WAC The issuer's response to an expedited review request may be delivered orally, and must be reduced to and issued in writing not later than 72 hours after the date of the decision. Regardless of who makes the issuer's determination, the time frame for providing a response to an expedited review request begins when the issuer first receives the request. WAC If the issuer requires additional information to determine whether the service being reviewed is covered, the issuer must request such information as soon as possible after receiving the request for expedited review. WAC An issuer may require exhaustion of the internal appeal process before appellant may request external review in urgent care situations that justify expedited review. WAC Expedited review must be conducted by appropriate clinician(s) in the same or similar specialty as would typically manage the case being reviewed. The clinician(s) must not have been involved in making the initial adverse determination. Independent Review of appeals (“IRO”) for both 42 U.S.C. §300gg-19(b) RCW 48.43.535(2) An enrollee may seek review by a certified independent review organization of an issuer's decision to deny, modify, reduce, or terminate coverage of or payment for a health care service, after exhausting the issuer's internal
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: RCW 48.43.043 (1)(a); 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 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 in-network 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 Congenital Abnormalities (Cont’d) Requirement for Coverage Requirement for Coverage (Cont’d) 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 after 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 the contract may require that notification of birth of a newly born child and payment of the required premium must be furnished to the issuer. The notification period must be no less than sixty days from the date of birth. Contract Standards Required Rate and Form Filing Instructions WAC Filing must comply with The SERFF Industry Manual, and Washington State SERFF Health and Disability Form Filing General Instructions. Rates must be filed concurrently with forms.
Cancellation WAC 284-44-310 (1)(a) The Contract Must: Have a continuous term; WAC 284-44-310 (1)(b) Fully insure the benefits of the persons who have paid for or contracted for covered health care services, which persons shall be designated as beneficiaries, when such services are not performed by the health care service contractor or a participant; WAC 284-44-310 (1)(c) Contain a provision that, in the of cancellation, the coverage shall continue with respect to services provided prior to the effective date of such cancellation; WAC 284-44-310 (1)(d) Contain a provision that it may not be cancelled without ninety days advance written notice to the insured or insurer by the cancelling party; and WAC 284-44-310 (1)(e) Contain a provision requiring not less than sixty days advance notice to the insurance commissioner, health care services division, by the insurer of any cancellation. Examination / Disapproval WAC 284-44-310 (2) The original or a true copy of the actual insurance contract or policy be filed with the insurance commissioner, health care services division, prior to its effective date. Contract Standards Required (Cont’d) RCW 48.44.020(2)(a) The filing must not: contain any inconsistent, ambiguous, misleading clauses, exceptions, or conditions, which unreasonably or deceptively affect the risk purported to be assumed in the general coverage of the contract; RCW 48.44.020(2)(b) have any title, heading, or other indication of its provisions which is misleading; RCW 48.44.020(2)(c) Solicit the purchase of health care services thereunder by deceptive advertising; (2)(d) contain unreasonable restrictions on the treatment of patients;
Retrospective denials Prohibited RCW 48.43.525(1) Plan must not retrospectively deny coverage for emergency and nonemergency care that had authorization under the plan’s written policies at the time the care was rendered. RCW 48.44.465 When an authorized plan representative approves a claim for an individual prescription, the plan may not later reject that claim. Contract Standards Required (Cont’d) Cost Sharing Requirement for Native Americans WAC Plan must not apply cost-sharing requirements to Native Americans purchasing a health benefit plan through the exchange, whose incomes are at or below three hundred percent of federal poverty level. Small Group Cost-Sharing WAC (2) A small group health benefit plan that includes the essential health benefits package may not impose annual cost-sharing or deductibles that exceed the maximum annual amounts that apply to high deductible plans linked to health savings accounts, as set forth in the most recent version of IRS Publication 969, pursuant to Section 106(c)(2) of the Internal Revenue Code of 1986, and Section 1302(c)(2) of PPACA. 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 lower-value setting. Issuer may still apply applicable 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. network
Coordination of Benefits (Cont’d) WAC A governmental plan, which, by law, provides benefits that are in excess of those of any private insurance plan or other nongovernmental plan; Definition of “Plan” for purposes of COB (Cont’d) WAC Automobile insurance policies required by statute to provide medical benefits; WAC Benefits provided as part of a direct agreement with a direct patient-provider primary care practice as defined at section 3, chapter 267, Laws of 2007. Contract Description of COB WAC 284-51-200(7) If a person has met the requirements for coverage under the primary plan, a closed panel plan in secondary position must pay benefits as if the covered person had met the requirements of the closed panel plan. COB may occur during the claim determination period even where there are no savings in the closed panel plan. WAC 284-51-195(5) "Closed panel plan" means a plan that provides benefits in the form of services primarily through providers employed by the plan, and that excludes benefits for services provided by other providers, except in cases of emergency or referral by a panel member. WAC The definition of “allowable expense” should be clear that when coordinating benefits, any secondary plans must pay an amount which, together with the payment made by the primary plan, cannot be less than the allowable expense the secondary plan would have paid if it was primary. A secondary plan must not be required to pay an amount in excess of its maximum benefit plus accrued savings. Rules for Coordination of Benefits WAC 284-51-205(1)(a) Contract may not contain any provisions that are inconsistent with or less favorable than COB rules: The primary plan must provide benefits as if the secondary plan did not exist. A plan may only take into consideration benefits provided by another plan when it is secondary to that other plan.
average plan participant. Required Offer of Disclosure Items (Cont’d) RCW 48.43.510 (1)(a) listing of covered benefits, including RX benefits, if any, copy of the current formulary, if any is used definitions of terms such as generic versus brand name, and policies regarding coverage of drugs, such as how they become approved or taken off the formulary, and how consumers may be involved in decisions about benefits; RCW 48.43.510 (1)(b) listing of exclusions, reductions, and limitations to covered benefits, and any definition of medical necessity or coverage criteria upon which they may be based; 48.43.510 (1)(c) statement of the carrier's policies for protecting the confidentiality of health information; 48.43.510 (1)(d) statement of the cost of premiums and any enrollee cost-sharing 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); WAC 284-170-260 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. Required Offer of Disclosure Items (Cont’d) 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 other 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 other than the primary care provider
Disclosures (Cont’d) Prescription Drug WAC If a carrier requires cost-sharing for enrollees receiving an as defined in WAC 284-170-470, then issuers must disclose that information to enrollees within their policy forms. A clear statement explaining that members may be eligible to receive an emergency fill for prescription drugs under the circumstances described in WAC 284-170-470 must be disclosed. This disclosure must include the process that members use to obtain an emergency fill, and cost-sharing requirements, if any, for an emergency fill. The applicable WAC also does not limit the fill to one per prescription medication per calendar year. – WAC 284-43-5110(5), WAC 284-43-5170 (1)(c), and WAC 284-170-470(8)(c). Eligibility Collection and Use of Genetic Information 42 U.S.C. 45 CFR 148.180(b)(1) Plan may not establish rules for eligibility (including continued eligibility) based on genetic information. (Genetic Information Nondiscrimination Act (“GINA”)) 42 U.S.C. Plan may not request or require individuals to undergo genetic testing. 45 CFR §148.180(e)(1) 42 U.S.C. 300gg- 4(d)(2) No genetic information may be required prior to enrollment, in connection with that enrollment. 45 CFR 148.180(f)(2)(i) 4(a)(6);
Women’s Direct Access (Cont’d) State Benefit Requirements for Maternity and Newborn Service State benefit requirements for Maternity and Newborn Services (Cont’d) WAC Maternity services must include diagnosis of pregnancy, prenatal care, delivery, care for complications of pregnancy, physician services, and hospital services 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; and RCW 48.44.344 Prenatal diagnosis of congenital disorders by screening/diagnostic procedures if medically necessary. WAC 284-43-5642(4)(d)(iii). Maternity and Newborn Services (EHB) (Cont’d) 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. These 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.
Medical Necessity (Cont’d) Requirements of Medical Necessity Determination Process (Cont’d) WAC Within thirty days of receiving a request, an issuer must furnish its medical necessity criteria for any or all essential health benefit categories to an enrollee or provider. Mental Health and Substance Use Disorder (MH/SUD) Services, Including Behavioral Health Treatment (EHB) Requirement for MH/SUD Coverage 42 USC §18021 (a)(1)(B); 42 USC (b)(1)(E); WAC 284-43-5642(5) Plan must cover "mental health and substance use disorder services, including behavioral health treatment" substantially equal to the base benchmark plan. For determining a plan's actuarial value, an issuer must classify as mental health and substance use disorder services, including behavioral health treatment, medically necessary care, treatment and services for mental health conditions and substance use disorders categorized in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including behavioral health treatment for those conditions. Required Services WAC Plan must include the following services, which are specifically covered by the base benchmark plan, and classify them as mental health and substance use disorder services, including behavioral health treatment:
MH/SUD Services (EHB) (Cont’d) Therapy Therapy (Cont’d) Requirement to Cover Requirement to Cover (Cont’d) WAC Contract must provide benefits for neurodevelopmental therapies. (Washington 2017 Base benchmark Plan subject to RCW 48.44.450(1)) O.S.T. v. Regence; WAC Must provide benefits for mental health diagnoses (Diagnoses listed in the DSM) without any “blanket limitations” (e.g., age six and under) O.S.T. v. Regence BlueShield, No. 88940-6 (WN October 9, 2014). RCW 48.44.450(2); Services covered must include physical, speech, and occupational therapies. WAC 284-43-5642(10)(a)(i). RCW 48.44.450(2) Benefits shall be payable only where the services have been delivered pursuant to the referral and periodic review of a holder
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.
Rules for “Originating Sites” Rules for “Originating Sites’ (Cont’d) RCW 48.43.735 (8)(d) "Originating site" means the physical location of a patient receiving health care services through telemedicine; and Forward Technology” Definition RCW 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
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. 45 CFR §146.121 (b)(2)(i)(C) Issuer may require the satisfaction of a deductible, or other requirement if the limit or cost-sharing requirement applies uniformly to all similarly situated individuals and is not directed at individual participants based on a health factor. In Premiums Contributions In Premiums and Contributions (Cont’d) 42 U.S.C. §300gg-4 (b); 45 CFR §146.121(c)(1) Issuer may not require a person, as a condition of enrollment or continued enrollment in the plan, to pay a premium or contribution greater than that for a similarly situated enrollee in the plan on any health factor of the individual or a dependent of the individual. This includes discounts, rebates, payments in kind, and any other premium differential mechanisms. 45 CFR 148.180(c)(1) Plan may not adjust premium amount on genetic information of the enrollee or a family member. 45 CFR 148.180 (c)(2)(ii) Manifestation of a disease or disorder in one individual also cannot be used as genetic information about other, covered, individuals.