Oral Services EHB (Cont’d) least the end of the month in which the enrollee turns age nineteen. WAC 284-43-5400; WAC 284-43-5602; WAC 284-43-5702 Lifetime and Annual Dollar limits 42 USC 42 USC §300gg-21(c) Stand Alone Dental Plans, that include family coverage (coverage for those over age 18) as excepted benefits plans, may have lifetime and annual limits, for those over age 18. Annual on Cost Sharing 45 CFR 156.150(a) The annual maximum cost sharing for pediatric EHBs cannot exceed $350 for one child and $700 for multiple children. Congenital Anomalies Mandated Benefit RCW 48.44.212(1) If contract covers dependents, it must provide coverage from the moment of birth. Coverage shall include, but not be limited to, coverage for congenital anomalies. Benchmark plan Must cover dentally appropriate services and supplies to treat a congenital anomaly and to restore a physical bodily function lost as a result of Injury or Illness, including cosmetic/reconstructive services. RCW 48.44.212(2) If payment of additional premium is required to provide coverage for the child, contract may require notification of birth and payment of the premium within no less than 60 days from date of birth. Contract Standards Contract Format Required RCW 48.44.020(2)(a) The filing must not contain any inconsistent, ambiguous or misleading clauses, or exceptions and conditions, which unreasonably or deceptively affect the risk purported to be assumed in the general coverage of the policy. Policy must contain clear, definitive, Washington state specific language for all terms, benefits and conditions.
Contract Examination and Standards (Cont’d) Contract Examination Discretionary Clauses Prohibited Discretionary Clauses Prohibited (Cont’d) WAC Contract may include provisions that inform enrollees that, as part of its routine operations, the carrier applies the terms of its contracts for making decisions, including determinations regarding eligibility, receipt of benefits and claims, or explaining its policies, procedures, and processes.
(1978) ); Great West Life Annuity Ins v. Knudson The contract cannot unreasonably restrict or delay the payment of benefits. Delays are not justified because the expenses incurred, or the services received, resulted from an act or omission of a third party Unfair and Discriminatory Practices Unfair and Discriminatory Practices (Cont’d) False Advertising RCW 48.44.110 The forms may not contain any false, deceptive, or misleading representation or advertising relative to the business of a HCSC or to any person engaged therein. of Contract Terms RCW 48.44.120 The forms may not contain any misrepresentation of the terms of any contract, or the benefits or advantages promised thereby, or use the name or title of any contract or class of contract misrepresenting the nature thereof. No guarantee of future payments RCW 48.44.130 Contract must not guarantee or agree to the payment of future dividends or future refunds of unused charges or savings. Misleading comparisons to terminate or retain contract RCW 48.44.140 The forms may not include misrepresentation or misleading comparisons to induce or attempt to induce any member of any HCSC to terminate or retain a contract or membership. Prohibited RCW 48.44.220 Form provisions cannot result in denial of coverage to any person solely on account of race, religion, national origin, or the presence of any sensory, mental, or physical handicap. Injury due to Intoxication or narcotics RCW 48.44.305 Plan must not deny coverage for treatment of an injury solely because the injury was caused by the enrolled participant's being intoxicated or under the influence of a narcotic.