Examination/ Disapproval RCW 48.18.110(2) RCW 48.43.005 the contract. Cannot contain any title, heading, or other indication of provisions which is misleading Must contain clear, definitive, WA state specific language for all terms, benefits, and conditions May not unreasonably restrict treatment or services Benefits must be reasonable in relation to the amount charged for the contract. Definitions in the contract must be consistent with those in RCW 48.43.005 and RCW 48.21. Exclusions, reductions and limitations RCW 48.18.140(f) Does the contract or certificate of coverage contain a listing of exclusions, reductions, and limitations to covered benefits either included with the benefit provisions, or under an appropriate caption? Is any exclusion, reduction, or limitation which applies only to a particular benefit Included with the applicable benefit provision? Required Format WAC 284-58-050(3) WAC 284-58-030(3) The style, arrangement, and over-all appearance of the contract must give no undue prominence to any portion of the text Is the type of a general style? Is the font size uniform, and of acceptable point size? “Text” means all printed matter except the name and address of the issuer, name or title of the policy, a brief description (if any), and captions and subcaptions Is there a form number in the lower left-hand corner of the page of each form, including riders and endorsements?
coverage. Plan must receive written certification by a treating physician that states the child is suffering from a serious illness or injury and the leave of absence is medically necessary. Coverage for individuals participating in approved clinical trials 42 USC § 42 USC § 42 USC § 300gg-8(b) 42 USC § 42 USC § If the plan provides coverage to “qualified individuals”: Cannot deny participation in an “approved clinical trial” for treatment of cancer or another disease or condition; Cannot deny, limit, or impose additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in the trial; Cannot discriminate on the basis of participation in the trial. This includes an enrollee participating in an approved clinical conducted outside the state in which the enrollee resides. “Qualified individual” means enrollee who is eligible to participate in the according to protocol, and either: (1) referring provider is a participating provider and has concluded that the would be appropriate for individual, or (2) individual provides medical or scientific information establishing that the would be appropriate. “Approved clinical trial” means a phase I, II, III, or IV clinical conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and it is either: (1) federally funded or approved, (2) conducted under FDA investigational new drug application, or (3) drug exempt from FDA investigational new drug application. “Routine patient costs” includes all items/services that would be typically covered if not enrolled in but not: (1) the investigational item, device, or service, (2) items solely for data collection or analysis needs, and (3) service clearly inconsistent with widely accepted standards of care. If an in-network provider is participating in a clinical trial, the issuer may require participation in the through the participating provider if the provider will accept the individual as a participant. Resources: ; ;
Diabetes (Cont’d) RCW 48.21.143(2)(b) RCW 48.21.143(3) RCW 48.21.143(5) visual blood sugar reading, and urine testing insulin and accessories to the pumps, insulin infusion devices, prescriptive oral agents for controlling blood sugar levels, foot care appliances for prevention of complications associated with diabetes, and glucagon emergency kits. Whether or not the contract provides Rx Benefits, does it provide: outpatient self-management training and education, including medical nutrition therapy, as ordered by the health care provider. Diabetes outpatient self-management training and education may be provided only by health care providers with expertise in diabetes. ISSUER may restrict patients to seeing only health care providers who have signed participating provider agreements with the ISSUER or an insuring entity under contract with the issuer. Benefits may be subject to customary cost sharing for all similar services or supplies within the policy. Services must be covered when deemed medically necessary. Disclosures RCW 48.43.510(3) WAC 284-43-820(4) RCW 48.43.510(1)(g) WAC 284-43-820 RCW 48.43.510(1)(a) Does the issuer provide to all enrollees and prospective enrollees a list of available disclosure items, including: Instructions on how to access and request copies in paper and electronic forms, and Web site links to the entire health plan disclosure information. Does the plan clearly and prominently display an offer to provide the following information before purchase or selection? Information must be provided upon request (either by paper or electronic, whichever is requested). Must be prominently displayed and accessible on the issuer’s website and easily understood by the average plan participant. listing of covered benefits, including RX benefits, if any, copy of the current formulary, if any is used
Emergency Treatment (Cont’d) RCW 48.43.005(13) WAC RCW 48.43.093 (1)(a) 42 U.S.C. RCW 48.43.093 (1)(a) 42 U.S.C. 45 C.F.R. 147.138(b)(2)(ii) 42 U.S.C. RCW 48.43.093 (1)(c) RCW 48.43.093 (1)(c) 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 would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy’? Does the plan cover emergency services necessary to screen and stabilize a covered person if a prudent layperson acting reasonably would have believed that an emergency medical condition existed? The contract 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. 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. 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. Emergency out-of-network coverage must be consistent with scope of regular contract benefits. Coverage of emergency services may be subject to applicable copayments, coinsurance, and deductibles, and an issuer may impose reasonable differential cost-sharing arrangements for emergency services, if such differential between in-network and out-of-network does not exceed fifty dollars.
RCW 70.126.020(3)(e) RCW 70.126.020(3)(f) RCW 48.21.220(2)(b) RCW 48.21.220(2)(a) RCW 48.21.220(2)(c) RCW 48.21.220(2)(d) RCW 48.21.220(2)(h) RCW 48.21.220(5) Services performed by family members; Services not included in the approved plan of treatment; or Supportive environmental materials (handrails, telephones, air conditioners, and similar devices) Is the coverage structured to create incentives for the use of home health care and hospice care as an alternative to hospitalization? The coverage may have the following characteristics: include reasonable deductibles, coinsurance provisions, and internal maximums; contain provisions for utilization review and quality assurance; require that home health agencies and hospices have written treatment approved by a physician licensed under chapter or RCW, and may require such treatment plans to be reviewed at designated intervals; The coverage may be structured so that services or supplies included in the primary contract are not duplicated in the optional home health and hospice coverage. The issuer, as a condition of reimbursement, may require compliance with home health and hospice certification regulations established by the United States Department of Health and Human Services. Hospice Care RCW 70.126.030(1) RCW 70.126.030(2) RCW 70.126.030(3)(a) RCW 70.126.030(3)(b) RCW 70.126.030(3)(c) RCW 48.21.220(2)(f) Must Hospice care be provided by a hospice? Must a written hospice care plan be approved by a physician and reviewed at designated intervals? Does hospice care include the following when ordered by a physician and included in the approved treatment plan: Short term inpatient care; Care of the terminally ill in an individual’s home on an outpatient basis; Respite care that is continuous care in the most appropriate setting for a maximum of five days per 3 months of hospice care?
RCW 48.21.241(2) Mandated Coverage RCW 48.21.241 (3) RCW 48.21.242 beverages. It is further characterized by a frequent or intense pattern of pathological use to the extent the user exhibits a loss of self-control over the amount and circumstances of use; develops symptoms of tolerance or physiological and/or psychological withdrawal if use of the controlled substance or alcoholic beverage is reduced or discontinued; and the user's health is substantially impaired or endangered or his or her social or economic function is substantially disrupted. Any disorder defined by the plan as being or as not being a substance use disorder must be defined to be consistent with generally recognized independent standards of current medical practice (for example, the most current version of the DSM, the most current version of the ICD, or state guidelines).” Does the plan provide mental health services and prescription intended to treat any disorder covered under the definition of mental health services? If there is a MOOP or stop loss, it must be a single limit or stop loss for medical, surgical, and mental health services. Health benefit may not reduce the number of mental health outpatient visits or mental health inpatient days below the level in effect on July 1, 2002. No preauthorization for mental health treatment rendered by a state hospital if the enrollee or covered dependent is involuntarily committed. Parity Requirement P.L. 110-343 Wellstone / Domenici Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”) RCW 48.21.241(2) WAC 284-43-992 Does the plan apply any financial requirement or treatment limitation to mental health or substance use disorder benefits that is more restrictive than those applied to medical/surgical benefits? No separate deductible for mental health benefits. Does the health plan provide MH/SUD benefits in every classification in which medical/surgical benefits are provided? 6 Classifications: Inpatient, in-network; inpatient, out-of-network; 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.
Mental Health or Substance Use Disorder (“MH/SUD”) (Cont’d) Therapy O.S.T. v. Regence BlueShield, No. 88940-6 (WN October 9, 2014). RCW 48.21.310(2) RCW 48.21.310(3) RCW 48.21.310(4) Does the contract provide benefits for neurodevelopment therapies? Must provide benefits for mental health diagnoses (Diagnoses listed in the DSM) without any “blanket limitations” (e.g., age six and under) Services covered must include physical, speech, and occupational therapies. Benefits shall be payable only where the services have been delivered pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or where covered services have been rendered by such licensee. Benefits shall be provided to restore and improve function, and for the maintenance of a covered individual in cases where significant deterioration in the patient's condition would result without the service. Benefits must be for medically necessary services. Benefits may not be subject to annual or lifetime dollar limits, but may be subject to visit limits, deductible, cost sharing, and requirements for written treatment plans. The contract may not exclude or limit coverage for assessment or testing to determine the amount and type of neurodevelopmental therapy needed. Pharmacy This section applies only to plans that cover prescription drugs. If the plan does not cover prescription drugs, you can skip this section and go on to the next section, PKU coverage.
Unfair and Discriminatory Practices (Cont’d) Unfair and Discriminatory Practices More favorable treatment of individuals with adverse health factors permitted 45 CFR §146.121 (g) Issuer may establish more favorable for individuals with an adverse health factor, such as disability, than for individuals without the adverse health factor.