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 An insurer 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 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 (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 trial
policyholder or retiree) is the primary plan and the plan that covers the person as a dependent is the secondary plan. WAC 284-51-205 (4)(a)(ii) If the person is a Medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, Medicare is: (4)(a))(ii)(I) Secondary to the plan covering the person as a dependent; and (4)(a)(ii)(II) Primary to the plan covering the person as other than a dependent (e.g., a retired employee); WAC 284-51-205 (4)(B) Then the of benefits is reversed so that the plan covering the person as an employee, member, subscriber, policyholder or retiree is the secondary plan and the other plan covering the person as a dependent is the primary plan. WAC Dependent child covered under more than one plan. Unless there is a court decree stating otherwise, plans covering a dependent child must determine the order of benefits as follows: Coordination of Benefits Rules for Coordination WAC For a dependent child whose parents are married or are living together, whether or not they have ever been married: (Cont’d) of Benefits (Cont’d) 284-51-205 (4)(b)(i)(A) The plan of the parent 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 child 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
evidence of the type usually considered and relied upon in making determinations of cost-effectiveness or clinical efficacy. However, health plans must not contain unreasonable limits. WAC 270(4) may use restricted networks. WAC Plans that use “gatekeepers” or “Medical Homes” for access to specialists may use them for access to specified categories of providers. No Separate Benefit WAC Issuers may not coverage for services by certain categories of providers solely as a separately-priced optional benefit (e.g., chiropractic care; acupuncture). Services by RNs, ARNPs 48.21.130; 48.21.141; Contract must cover services performed by a Registered Nurse, Advanced Registered Nurse Practitioner, or podiatrist if: and the service is within the scope of the provider’s license, and Podiatrists The contract would have covered the service if it had been performed by a physician licensed under Chapter 18.71 RCW. 48.43.190 Plan must cover chiropractic care on the same basis as other care. Every Category of Provider (Cont’d) Coverage of Chiropractic Care RCW 48.21.142 Benefits cannot be denied for any service performed by a chiropractor if the service was within the lawful scope of that license and the contract would have provided benefits if the service had been 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. Denturist if Dental Covered RCW 48.21.148; 48.43.180 If plan offers dental coverage, Denturist must be able to provide services within the of their license if the plan would provide the same benefits performed by a dentist.
Coverage of Optometry RCW 48.21.140 Benefits must not be denied for any eye care service rendered by an optometrist licensed Chapter RCW, if the service was within the lawful scope of their license, and the contract would have provided the benefits if rendered by a physician licensed under Chapter RCW. Experimental or Investigational Definition Required 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. Treatment WAC The definition must include an identification of the authority or authorities will make a determination of which services will be considered to be experimental or investigational. Contract Must State Criteria for Determination WAC If the disability insurer or an affiliated entity is the authority making the determination, it must state the criteria it will utilize to make the determination. This requirement may be satisfied by using one or more of the following statements, or other similar statements: Experimental / Investigational Treatment (Cont’d) Contract Must Criteria for Determination (Cont’d) WAC "In determining whether services are experimental or investigational, the plan will consider whether the services are in general use in the medical community in the state of Washington, whether the services are under continued scientific testing and research, whether the services show a demonstrable benefit for a particular illness or disease, and whether they are proven to be safe and efficacious." WAC "In determining whether services are experimental or investigational, the plan will consider whether the services result in greater benefits for a particular illness or disease than other generally available services, and do not pose a significant risk to health or safety of the patient."
RCW 48.46.280 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. (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. Prohibited limitations Prohibited Limitations (Cont’d) WAC (3)(c)(i)&(ii) Plan may not include a waiting period for transplant services. Hospitalization (EHB) (Cont’d) 42 U.S.C. 18116, §1557 Plan may not exclude coverage for sexual reassignment treatment, surgery or counseling services. RCW 48.30.300; RCW 49.60.040; WAC 284-43-5642(3)(c)(ii) Allowable limitations on Hospitalization benefits WAC Plan may include the following limitations on services in the hospitalization category: Sixty inpatient days per calendar year for illness, injury or physical disability in a skilled nursing facility; WAC Thirty inpatient rehabilitation service days per calendar year. For purposes of determining actuarial value, this benefit may be classified to the hospitalization category or to the rehabilitation services category, but not to both. benefit requirements in RCW 48.43.185; WAC State benefit requirements classified to the hospitalization category are:
(b)(1)(D) delivered to women during pregnancy and in relation to delivery and recovery from delivery and to newborn children. Required Maternity and Newborn Services WAC Plan must 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; WAC Complications of pregnancy such as, but not limited to, fetal distress, gestational diabetes, and toxemia; and WAC Termination of pregnancy. Termination of pregnancy may be included in an issuer's essential health benefits package, but nothing in this section requires an issuer to offer the benefit, consistent with 42 U.S.C. 18023 (b)(a)(A)(i) and 45 C.F.R. 156.115. Maternity and Newborn Required Maternity and RCW 48.42.100(2) Health care practitioners that provide women's health care services must include, but need not be limited to: Services (EHB) (Cont’d) Newborn Services (Cont’d) Any generally recognized medical specialty of practitioners licensed under chapter or RCW who provides women's health care services; practitioners licensed under chapters and RCW when providing women's health care services; midwives licensed under chapter RCW; and advanced registered nurse practitioner specialists in women's health and midwifery under chapter RCW.
45 CFR §147.131 (e)(1) The carrier satisfies its obligations to provide contraceptive coverage if it reasonably and in good faith relies on a by the employer that it is eligible for this accommodation and the carrier complies with these obligations. Application to Student Health Coverage 45 CFR §147.131 (f) The requirements apply to student health insurance coverage arranged by an eligible organization that is an institution of higher education. Medical Necessity Requirements of Medical WAC Contract must specifically explain issuer's medical necessity determination process. Necessity Determination Process WAC Process must: be conducted fairly, and with transparency to enrollees and providers, at a minimum when an enrollee or their representative appeals or seeks review of an adverse benefit determination; WAC Include consideration of services that are a logical next step in reasonable care if they are appropriate for the patient; Medical Necessity (Cont’d) Requirements of Medical Necessity WAC Identify the information needed in the decision-making process and incorporate appropriate outcomes within a developmental framework; Determination Process (Cont’d) WAC Ensure that when the interpretation of the medical purpose of interventions is part of the medical necessity decision making, the interpretation standard can be explained in writing to an enrollee and providers, and is broad enough to address any of the services encompassed in the ten essential health benefits categories of care; WAC Comply with inclusion of the ten essential health benefits categories;
Use Disorder Services, Including Behavioral Health Treatment (Cont’d) these six classifications and therefore not subject to the parity analysis. A health plan or issuer must treat the least restrictive level of the financial requirement or quantitative treatment limitation that applies to at least two-thirds of medical/surgical benefits across all provider tiers in a classification as the predominant level that it may apply to mental health or substance use disorder benefits in the same classification. (EHB) (Cont’d) WAC WAC Parity analysis must be done for each classification and applies to all treatment limitations (frequency of treatment, number of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration of treatment). Look at: WAC Quantitative treatment limitations: expressed numerically (such as fifty outpatient visits per year) Includes annual, episode, and lifetime day and limits. WAC Nonquantitative treatment limitations (“NQTL”): processes, strategies, or evidentiary standards, or other factors that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. Includes, but not limited to: Mental Health and Substance Use Mental Health Parity (Cont’d) WAC (a) Limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; Disorder (b) Formulary design; Services, Including (c) For plans with multiple network tiers (such as preferred providers and participating providers), network tier design; Behavioral Health (d) Standards for provider admission to participate in a network, including reimbursement rates; Treatment (EHB) (e) Methods for determining usual, customary, and reasonable charges;
(Cont’d) (f) Use of fail-first policies or step therapy protocols; (g) Exclusions based on failure to complete a course of treatment; and (h) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit scope or duration of benefits. WAC A permanent exclusion of all benefits for a particular condition or disorder is not an NQTL; may be allowable if not otherwise prohibited. (See definition of “Treatment Limitations”) WAC All health plan standards must comply with the parity requirement. Includes: in-and-out-of-network geographic limitations, limitations on inpatient services for situations where the participant is a threat to self or others, exclusions for and involuntary holds, experimental treatment limitations, service coding, exclusions for services provided by clinical social workers, and network adequacy. Mental Health and Substance Use Disorder Services, Mental Health Parity (Cont’d) WAC WAC If a health plan or issuer classifies providers into and varies based on the different tiers, no financial requirement or treatment limitation on MH/SUD benefits may be more restrictive than what applies to substantially all medical/surgical benefits in that tier. Including Behavioral Health Treatment WAC No NQTL may be imposed on MH/SUD in any classification unless any processes, strategies, evidentiary standards or other factors used to apply the NQTL to MH/SUD benefits are in parity with those used to apply it to medical/surgical benefits in the same classification. (EHB) (Cont’d) Prohibited Exclusions WAC Benefits for actual treatment and services rendered may not be denied solely because a course of treatment was interrupted or was not completed.
5782(2)(f)(i) One comprehensive low vision evaluation every five years; WAC High power spectacles, magnifiers and telescopes as medically necessary, with reasonable limitations permitted; and WAC Follow-up care of visits in any five-year period, with prior approval. Allowed Exclusions WAC The plan may include the following exclusions: Visual therapy that is otherwise covered under the medical/surgical benefits of the plan; and (3)(b) Ordering two of glasses in lieu of bifocals. PKU Phenylketonuria Requirement to RCW 48.21.300(2) Plan must provide coverage for the formulas necessary for the treatment of phenylketonuria. Formula WAC Coverage may be limited to the and customary charge for such formulas. Coverage may be subject to deductibles, copayments, coinsurance or other reductions applicable to other benefits. Premium charged must be no greater as a result of a family or individual receiving PKU benefits. PKU (Cont’d) Coverage Requirement WAC Coverage for the formulas may be made subject to deductibles, copayments, coinsurance or other reductions only to the extent that such deductibles, copayments, coinsurance or other reductions do not exceed those applicable to common sicknesses or disorders in the particular contract. Prescription Drug Services (EHB) Required Prescription Drug Services 42 USC §18021(a)(1)(B); 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
medication or chemotherapy that is administered intravenously or by injection. WAC Issuer may not reclassify an anticancer medication or increase an enrollee's out-of-pocket costs as a method of compliance with these requirements. Prescription Synchronization 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) If an enrollee requests medication synchronization for a new prescription, the health plan must permit filling the drug: 48.43.096 (1)(a)(i) for less than a one-month supply of the drug if synchronization will require more than a fifteen-day supply of the drug; or 48.43.096 (1)(a)(ii) for more than a one-month supply of the drug if synchronization will require a fifteen-day supply of the drug or less. Prescription Drug Services (EHB) (Cont’d) Prescription 48.43.096 (1)(b) The health benefit plan shall 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. RCW 48.43.096 (1)(c) The health benefit plan shall 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: (1)(c)(i) Discounting the copayment rate by fifty percent; 48.43.096 (1)(c)(ii) Discounting the copayment rate based on fifteen-day increments; or 48.43.096 (1)(c)(iii) Any method that meets the intent of this section and is approved by the OIC. To have an alternative method approved by OIC, the issuer should submit a request to the Manager of the Health &
essential health benefits package. Issuers must provide coverage for a service provided via telemedicine if: the service be covered when provided in person; and RCW 48.43.735 (1)(b) the service is medically necessary; and (1)(c) the service is an EHB. Requirements for Coverage 48.43.735 (2)(a) If the service is provided through store and forward technology, there must be an associated office visit between the covered person and the referring health care provider. The associated office visit may also occur via telemedicine. (Cont’d) (2)(b) Reimbursement of store and forward technology is available only for those covered services specified in the negotiated agreement between the health plan and health care provider. Telemedicine (Cont’d) Rules for “Originating 48.43.735 (3)(a) An originating site for a telemedicine health care service includes a: Hospital; Sites” (3)(b) Rural health clinic; (3)(c) Federally qualified health center; (3)(d) Physician's or other health care provider's office; (3)(e) Community mental health center; (3)(f) Skilled nursing facility; or (3)(g) Home; or (3)(h) Renal dialysis center, except an independent renal dialysis center. RCW 48.43.735(4) Any originating site may charge a facility fee for infrastructure and preparation of the patient. Reimbursement must be subject to a negotiated agreement between the originating site and the health plan. A distant site or any other site not identified above may not charge a facility fee.