ANALYST CHECKLIST Disability Carrier – INDIVIDUAL MAJOR MEDICAL PLANS Issuer: ___________________________ SERFF Tracker ID: ___________________ GENERAL REVIEW REQUIREMENTS Authority to Review Contract – RCW 48.18.100, RCW 48.43.715 WAC 284-43-5622, WAC 284-43-5642, WAC 284-43-5702, WAC 284-43-5782 Topic Sub Topic Reference Specific Issue Form and page or section Additional Information / Comments Alternative to Hospitalization Requirement To cover home care in lieu of hospitalization WAC As an alternative to hospitalization or institutionalization and with the intent to cover placement of the enrollee in the most appropriate, cost-effective setting, plan must include substitution of home health care in lieu of hospitalization or other institutional care, furnished by home health, hospice and home care agencies licensed under chapter RCW, at equal or lesser cost. WAC Such expenses may include coverage for durable medical equipment which permits the insured to stay at home, care provided in Alzheimer's centers, adult family homes, assisted living facilities, congregate care facilities, adult day health care, home health, hospice and home care, or similar alternative care arrangements which provide necessary care in less restrictive or less expensive environments.
General Ambulatory Patient Services Requirements (Cont’d) 45 CFR §147.130 Behavioral management activities, such as weight-loss goals. Optional Ambulatory WAC (1)(b)(i) Plan may, but is not required to, cover: Infertility treatment and reversal of voluntary sterilization;
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 pay for in-network services. Congenital Abnormalities Congenital Abnormalities Requirement for Coverage RCW 48.20.430(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. Requirement for Coverage (Cont’d) RCW 48.20.430(2) If payment of an additional premium is required to provide coverage for a child, 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 Examination and Standards Rate and Form Filing Instructions WAC Filing must be complete and comply with The SERFF Industry Manual, and Washington State SERFF Health and Disability Form Filing General Instructions. WAC Rates must be filed concurrently with forms. Examination/ Disapproval RCW 48.18.110 (1)(c) The filing must not: contain any inconsistent, ambiguous, misleading clauses, exceptions, or conditions, unreasonably or deceptively
Disclosures (Cont’d) Required Offer of Disclosure Items RCW 48.43.510 (1)(g) WAC Plan must clearly and prominently display an offer to provide the information listed below 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. 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 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 other 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 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 RCW 48.43.510 (1)(g); 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. sharing
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; 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 and whether any entity must authorize the referral; 48.43.510 (2)(c) Procedures, if any, that an enrollee must first follow for obtaining prior authorization for health care services; RCW 48.43.510 (2)(d) A written description of any reimbursement or payment arrangements between the issuer and providers, including capitation provisions, fee-for-service provisions, and health care delivery efficiency provisions; Required of Disclosure Items (Cont’d) RCW 48.43.510 (2)(e) Descriptions and justifications for provider compensation programs, including any incentives or penalties that are intended to encourage providers to withhold services or minimize or avoid referrals to specialists; RCW 48.43.510 (2)(f) An annual accounting of all payments made by the carrier which have been counted against any payment limitations, visit limitations, or other overall limitations on a person's coverage under a plan; and RCW 48.43.510 (2)(h) Accreditation status with one or more national managed care accreditation organizations, and whether the carrier tracks its health care effectiveness performance using the health employer data information set (HEDIS), whether it publicly reports its HEDIS data, and how people can access its HEDIS data.
Emergency Medical Services (EHB) (Cont’d) Required Emergency Services (Cont’d) limitations on services in the emergency medical services category. RCW 48.43.093 Plan must include the services necessary to screen and stabilize a covered person, classified to the emergency medical services category. WAC 284-43-5642(2)(d) 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 Plan’s definition of "Emergency medical condition" must be consistent with RCW 48.43.005(13), or WAC 284-43-0160(7) which states: “’Emergency Medical Condition’ means the emergent and acute onset of a symptom or symptoms, including severe pain, that
Services by RNs, ARNPs, and Podiatrists RCW 48.20.411; RCW 48.20.390 Contract must cover services performed by a Registered Nurse, Advanced Registered Nurse Practitioner, or podiatrist if: the service is within the scope of the provider’s license, and The contract would have covered the service if it had been performed by a physician licensed under Chapter 18.71 RCW. Coverage of Chiropractic care RCW 48.43.190 Plan must cover chiropractic care on the same basis as other care. RCW 48.20.412 Benefits cannot be denied on the basis that a service is not 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 chiropractors. Denturist if Dental Covered RCW 48.20.418; RCW 48.43.180 If plan offers dental coverage, Denturist must be able to provide services within the scope of their license if the plan would provide the same benefits performed by a dentist. network
RCW 48.43.038 (3) (c) Issuer provides a 90 day discontinuation notice to each enrollee, offers each the option to enroll in any of the issuer’s individual plans, and acts uniformly without regard to any health status-related factor; or RCW 48.43.038 (3)(d) Issuer discontinues offering all individual health coverage in the state and discontinues all existing individual health plans, if the issuer provides 180 day advance notice to the commissioner and each enrollee. In this case, the carrier may not issue any individual health coverage in Washington for five years from the date of the discontinuation of the last health plan.
Hospitalization (EHB) (Cont’d) Required Services (Cont’d) WAC (3)(a)(iii) Transplant services, supplies and treatment for donors and recipients, including the transplant or donor facility fees performed in either a hospital setting or outpatient setting; (3)(a)(iv) Dialysis services delivered in a hospital; WAC (a)(v) Artificial organ transplants based on an issuer's medical guidelines and manufacturer recommendations; and WAC (a)(vi) Respite care services delivered on an inpatient basis in a hospital or skilled nursing facility. Optional Hospitalization Services WAC (3)(b) Plan may, but is not required to, include the following services as part of the EHB-benchmark package. The base-benchmark plan specifically excludes these services. If an issuer includes these benefits in a health plan, the issuer should not include the following benefits in establishing actuarial value for the hospitalization category: WAC (b)(i) Hospitalization where mental illness is the primary diagnosis to the extent that it is classified under the mental health and substance use disorder benefits category; WAC (3)(b)(ii); Cosmetic or reconstructive services and supplies except in the treatment of a congenital anomaly, to restore a physical bodily
Mental Health and Substance Use Disorder (MH/SUD) Services, Including Behavioral Health Treatment (EHB) (Cont’d) Mental Health Parity (Cont’d) 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.
45 CFR § 92.8(a)(4) How to obtain these aids and services. (Cont’d) Language Access (Cont’d) 45 CFR § 92.8(a)(5) Contract must identify and provide contact information for the responsible employee designated to coordinate its nondiscrimination efforts, including complaints. 45 CFR § 92.8(a)(6) and (7) Contract must notify enrollee of the availability of the grievance procedure and how to file a grievance, and how to file a discrimination complaint with the federal Office of Civil Rights. 45 CFR § 92.8(d)(1) Contract must include taglines in at least the top 15 languages spoken by individuals with limited English proficiency of the relevant State or States. Pediatric Oral Services (EHB) Requirement to Cover Pediatric Oral Services 42 USC §18021 (a)(1)(B); 42 USC 18022 (b)(1)(J) A health plan must include pediatric dental benefits as an embedded set of benefits, or through a combination of a health benefit plan and a dental plan that includes pediatric dental benefits certified as a qualified dental plan. WAC WAC Plan must satisfy the requirement in one of two ways: The plan includes pediatric dental benefits as an embedded benefit (issuer must submit the “Embedded Pediatric Dental EHB Checklist” in addition to this checklist); or WAC The plan does not have pediatric dental benefits, and the issuer receives reasonable assurance that the applicant has obtained or will obtain pediatric dental benefits through a stand-alone QDP. This reasonable assurance must be received by the issuer within 60 days. Discrimination
Prescription Drug Services (EHB) (Cont’d) Drug Exception/ its coverage determination no later than 72 hours following receipt of the request. WAC 284-43-5080(3)(b) 45 CFR 156.122 (c)(1)(iii) A health plan that grants a standard exception request must provide coverage of the non-formulary drug for the duration of the prescription, including refills. WAC 284-43-5080(3)(b) 45 CFR 156.122 (c)(2)(i) Expedited exception request. Plan must have a process for an enrollee, the enrollee's designee, or the prescriber to request an expedited review based on exigent circumstances. WAC 284-43-5080(3)(c) 45 CFR 156.122 (c)(2)(ii) Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a non-formulary drug. WAC 45 CFR 156.122 (c)(2)(iii) Plan must make its determination on an expedited review request and notify the enrollee (or designee) and prescriber of its determination no later than 24 hours following receipt of the request. WAC 284-43-5080(3)(c)(i) 45 CFR 156.122 (c)(2)(iv) If exception is granted, plan must provide coverage of the non-formulary drug for the duration of the exigency. WAC 284-43-5080(3)(c)(ii) 45 CFR 156.122 (c)(3)(i) External exception request review. If the Plan denies a request for a standard exception or an expedited exception, the plan must have a process for the enrollee, the enrollee's designee, or the enrollee's prescriber to request that the original exception request
Prescription Drug Services (EHB) (Cont’d) request that the provider submits additional information to make the prior authorization determination: (5)(a)(i)(C)(i) The issuer must give the provider forty-eight hours to submit the requested information; WAC (5)(a)(i)(C)(ii) The issuer must then approve or deny the request within forty-eight hours of the receipt of the requested additional information and include the authorization number in its approval; 2020(5)(a)(ii) For nonurgent care review requests: WAC (5)(a)(ii)(A) Must approve the request within five calendar days if the information is sufficient to approve the claim and include the authorization number in its approval; WAC (5)(a)(ii)(B) Must deny the request within five calendar days if the requested service is not medically necessary and the information provided is sufficient to deny the claim; or WAC (5)(a)(ii)(C) Within five calendar days, if the information provided is not sufficient to approve or deny the claim, the issuer must request that the provider submits additional information to make the prior authorization determination: Requirement to Maintain 2020(5) (a)(ii)(C)(I) The issuer must give the provider five calendar days to submit the requested additional information; Drug Utilization Review Program 2020(5) (a)(ii)(C)(II) The issuer must then approve or deny the request within calendar days of the receipt of the additional information and include the authorization number in its approval. Publishing Formulary 45 CFR 156.122 (d)(1) Plan must publish an up-to-date, accurate, and complete list of all covered drugs on its formulary drug list, including any tiering structure and any restrictions on the manner in which a drug
RCW 18.64.530(1) • The refill is requested by a patient at or after seventy percent of the predicted days of use of 18.64.530 (1)(a) The date the original prescription was dispensed to the patient; or 18.64.530 (1)(b) The date that the last refill of the prescription was dispensed to the patient; RCW 18.64.530(2) The prescriber indicates on the original prescription that a specific number of refills will be needed; and
Prescription Drug Services (EHB) (Cont’d) Preventive and Wellness Services, Including Chronic Disease Management (EHB) Definition of Preventive and Wellness Services, Including Chronic Disease Management 42 USC §18021 (a)(1)(B); 42 USC 18022(b)(1)(I); WAC Plan must cover "preventive and wellness services, including chronic disease management" in a manner substantially equal to the base-benchmark plan. For purposes of determining a plan's actuarial value, an issuer must classify as preventive and wellness services, including chronic disease management, the services that identify or prevent the onset or worsening of disease or disease conditions, illness or injury, often asymptomatic; services that assist in the multidisciplinary management and treatment of chronic diseases; and services of particular preventative or early
identification of disease or illness of value to specific populations, such as women, children and seniors. Requirements for Preventive and Wellness Services Requirements for Preventive and Wellness Services (Cont’d) WAC (9)(a); WAC If the plan does not have in its a provider who can perform the particular service, then the plan must cover the item or service when performed by an out-of-network provider and must not impose cost-sharing with respect to the item or service. WAC (9)(a) Plan must not limit sex-specific recommended preventive services based on an individual's sex assigned at birth, gender identity or recorded gender. If a provider determines that a recommended preventive service is medically appropriate for an individual, and the individual otherwise satisfies the coverage requirements, the plan must provide coverage without cost-sharing. WAC Plan must include the following services as preventive and wellness services, including chronic disease management: Immunizations recommended by the Centers for Disease Control's Advisory Committee on Immunization Practices; WAC (9)(b)(ii)(A) Screening and tests for which the U.S. Preventive Services Task Force for Prevention and Chronic Care have issued A and B recommendations on or before the applicable plan year; WAC (9)(b)(ii)(B) To the extent not specified in a recommendation or guideline, a plan may rely on the relevant evidence base and reasonable medical management techniques, based on necessity or appropriateness, to determine the frequency, method, treatment, or setting for the provision of a recommended preventive health service;
WAC (9)(b)(v) Chronic disease management services, which typically include, but are not limited to, a treatment plan with regular monitoring, coordination of care between multiple providers and settings, medication management, evidence-based care, measuring care quality and outcomes, and support for patient self-management through education or tools; and WAC Wellness services. Prohibited Limitations Prohibited Limitations on Preventive and Wellness Services (Cont’d) 42 USC 300gg-13 (a) Plan may not include cost sharing requirements with respect to the preventive services listed WAC 284-43-5642(9) (b)(i) through (iv) that are provided in-network. WAC WAC The provider network must include preventive and wellness services, including chronic disease management and smoking cessation services as defined in RCW (37) and WAC (9) and (9). If services are provided through a quit-line or help-line, the issuer must ensure that when follow-up services are medically necessary, the enrollee will have access to sufficient information to access those services within the service area. Contracts with quit-line or help-line services are subject to the same conditions and terms as other provider contracts under this section.
Preventive and Wellness WAC Plan must cover medically necessary neurodevelopmental therapy for any DSM diagnosis without blanket exclusions. (e.g., Plan may not limit outpatient neurodevelopmental therapy services to persons age six and under.) State Benefit Requirements Classified in Preventive and Wellness Services Benefit Requirements Classified in Preventive and Wellness Services (Cont’d) RCW 48.43.043 (1)(b)(i) (1)(b)(ii) benefit requirements classified in this category are: Colorectal cancer screening. WAC 284-43-5642(9)(e)(i) for a covered individual who is at least 50 years old; Less than 50 and at high risk or very high risk for colorectal cancer. RCW 48.20.393 Mammogram services, both diagnostic and screening. WAC 284-43-5642(9)(e)(ii) WAC Plan can apply standard contract provisions for diagnostic mammograms applicable to other benefits such as deductible cost sharing. E.g., may apply deductible and copay requirements; and RCW 48.20.392(1) Prostate cancer screening if delivered upon the recommendation of the patient’s physician, ARNP, or Physician Assistant. WAC 284-43-5642(9)(e)(iii) WAC WAC Some state benefit requirements are limited to those receiving pediatric services, but are classified to other categories for purposes of determining actuarial value. These benefits include: Neurodevelopmental therapy, consisting of physical, occupational and speech therapy and maintenance to restore or improve function based on developmental delay, which cannot be combined with rehabilitative services for the same condition. This state benefit requirement may be classified to ambulatory
Discrimination on the Basis of a Health Factor Prohibited – In Premiums or Contributions payments in kind, and any other premium differential mechanisms. 45 CFR 148.180 (c)(1) Plan may not adjust premium amount based 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.