Freedom to Contract for Non-covered Services Freedom to Contract for Services (Cont’d) RCW 48.43.085 Contract must provide that enrollees are free to contract for services outside the plan on any or conditions the enrollees choose. RCW 48.44.495(1)(a) Contract may not: require, directly or indirectly, that a participating provider dentist provide non-covered services to an enrollee at a fee set by, or subject to the approval of, the issuer, including services that be reimbursable but for the application of contractual limitations (e.g., benefit maximums, deductibles, coinsurance, waiting periods, or frequency limitations), under the applicable group contract or individual contract; nor RCW 48.44.495(1)(b) Prohibit, directly or indirectly, a participating provider dentist from offering or providing enrollees non-covered services on any or conditions acceptable to the dentist and the enrolled participant. Plan May Not Discourage Providers from Informing Enrollees RCW 48.43.510(6) Plan must not preclude or discourage providers from: RCW 48.43.510(6) Informing enrollees of care they require, including treatment options; RCW 48.43.510(6) Informing enrollees whether in the providers' view such care is covered the plan; RCW 48.43.510(6) Advocating on behalf of an enrollee with a carrier; or RCW 48.43.510(7) Discussing the comparative merits of different carriers with their providers, even if providers are critical of a carrier. Denturist Services Covered RCW 48.43.180 RCW 48.44.500 Plan must not deny benefits for any service performed by a denturist licensed under Chapter RCW if the service was within the lawful scope of their license, and the plan would have Non-
Contract Examination and Standards (Cont’d) 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.
Crown and fixed bridge (Cont’d) Benchmark plan Repair of implant-supported prosthesis or abutment. May be limited to one per tooth per enrollee lifetime. Diagnostic Services Diagnostic Services (Cont’d) Required Diagnostic Services Required Diagnostic Services that Must be Provided Without Cost Sharing (Cont’d) WAC See, also, WAC Must cover diagnostic services in a manner substantially equal to the base-benchmark plan. This must include, at least, the following services, which must be covered without cost sharing (as they are covered as preventive services under the base benchmark plan): WAC Diagnostic exams once every six months, beginning before one year of age; WAC Limited oral evaluations when necessary to evaluate for a specific dental problem or oral health complaint, dental emergency or referral for other treatment; WAC Limited visual oral assessments or screenings, limited to two per member per calendar year, not performed in conjunction with other clinical oral evaluation services; Benchmark Plan Problem focused oral examinations; WAC Two sets of bitewing X rays per member per year for a total of four bitewing X rays per member per year; (5)(d) Cephalometric films once in a two-year period; WAC Panoramic X rays (complete intraoral mouth X rays) once every three years; Benchmark Plan Complete intraoral mouth X rays once every three years;
Periodontics Required Periodontic Services (Cont’d) WAC Periodontal scaling and root planning once per quadrant in a period for ages thirteen and older; WAC Periodontal maintenance once per quadrant in a twelve-month period for ages thirteen and older; Benchmark plan Complex periodontal procedures (osseous surgery including flap entry and closure and mucogingivoplastic surgery) limited to once per Member per quadrant in a five-year period; Benchmark plan Debridement limited to once per Member in a period; and Benchmark plan Gingivectomy and gingivoplasty limited to once per Member per quadrant in a three-year period. 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, Preventive Services. No Retracting Authorization RCW 48.44.465 An HCSC may not retract an authorization issued by any means on a pharmacy claim. Statement Required WAC Contract must include “Your Right to Safe and Effective Pharmacy Services” statement. WAC Prescription benefit may include cost control measures, including requiring preferred drug substitution in a therapeutic class, if