Clinical Trials (Cont’d) Requirements for coverage (Cont’d) WAC (4)(e) "Life threatening condition" means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted. Colorectal Cancer Screening Colorectal Cancer Screening (Cont’d) Requirement for Coverage RCW 48.43.043(1) Plan must provide coverage for colorectal cancer exams and lab tests consistent with the A and B recommendations of the USPSTF or the CDC. Coverage must be provided: RCW 48.43.043(1)(a) (1)(b)(i) For any of the colorectal screening exams and tests in the selected recommendations, at a frequency identified therein, as deemed appropriate by the patient's physician after consultation with the patient; and To an enrollee who is: At fifty years old; or RCW 48.43.043 (1)(b)(ii) Less than fifty years old and at high risk or very high risk for colorectal cancer according to such guidelines or recommendations. Burdensome Requirements Prohibited RCW 48.43.043(2) Plan design must not require patients and providers to meet burdensome criteria or overcome significant obstacles to secure such coverage. Enrollee may not be required to pay an additional deductible or coinsurance for testing greater than a deductible or coinsurance for similar benefits. If the plan does not cover a similar benefit, a deductible or coinsurance may not
Coordination of Benefits (Cont’d) Rules for Coordination of Benefits (Cont’d) WAC (2)(a) Except as provided below, a plan that contains noncompliant COB provisions is always the primary plan unless the provisions of both plans state that the complying plan is primary. WAC (2)(a) A plan with of benefit determination rules that comply with the WAC rules (complying plan) may coordinate its benefits with a plan that is "excess" or "always secondary", or that uses order of benefit determination rules inconsistent with the WAC rules (noncomplying plan) on the following basis: (2)(a)(i) If the complying plan is the primary plan, it must provide its benefits first; WAC (2)(a)(ii) If the complying plan is the secondary plan under Chapter 284-51 WAC, it must provide its benefits first, but the amount of benefits payable must be determined as if the complying plan were the secondary plan. In this situation, the payment is the limit of the complying plan's liability; and WAC (2)(a)(iii) If the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within forty-five days after the date on the letter making the request, the complying plan may assume the benefits of the noncomplying plan are identical to its own, and pay its benefits accordingly. If, within twenty-four months after payment, the complying plan receives information as to the actual benefits of the noncomplying plan, it must adjust payments accordingly between the plans.
Rules for Secondary Plan Payment (Cont’d) WAC 284-51-230(2)(a) If the plan is secondary, all secondary gatekeeper requirements will be waived if the gatekeeper requirements of the primary plan have been met. WAC If the primary plan becomes secondary during a course of treatment, the new primary plan must make reasonable provision for continuity of care if one or more treating providers are not in the new primary plan's network. WAC 284-51-230(4) When a plan is secondary, it may reduce its benefits so the total benefits provided by all plans during a claim determination period do not exceed one hundred percent of the total allowable expenses. The secondary plan must calculate and record its savings from the amount it would have paid had it been primary, and must use these savings to pay any allowable expenses not otherwise paid, that are incurred by the covered person during the claim determination period, so that one hundred percent of the total allowable expenses incurred are paid during the claim determination period. Required Provisions: If the plan provides for COB, it must contain provisions substantially as follows: “Facility of Payment” WAC "If payments that should have been made under this plan are made by another plan, the issuer has the right, at its discretion, to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision. To the extent of such payments, the issuer is fully discharged from liability under this plan." “Right of Recovery” WAC "The issuer has the right to recover excess payment whenever it has paid allowable expenses in excess of the maximum amount of payment necessary to satisfy the intent of this provision. The
Coordination of Benefits (Cont’d) Dependent Enrollment Requirements Newborn Coverage (“Erin Act”) RCW 48.43.115(3)(f) Coverage for newborns must be no less than the coverage of the child's mother for no less than three weeks (21 days), even if there are separate hospital admissions.
Age Limit (Cont’d) Issuer may require proof of incapacity and dependency within thirty-one days of the child's attainment of the limiting age and subsequently, but not more than annually after the first two years following attainment of the limiting age. Newborn Child Enrollment RCW 48.44.212(1) If plan covers dependent children of the enrollee, it must provide coverage for newborn infants of the enrollee from and after the moment of birth. Must include coverage for congenital anomalies of such infant children from the moment of birth. RCW 48.44.212(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 contractor. The notification period shall be no less than sixty days from the date of birth.
Description of Provider Tiering Description of Provider Tiering (Cont’d) WAC The tier in which each participating provider or facility is assigned. Cost Sharing for Emergency Prescription Fills WAC WAC 284-43-5170 (1)(c) If the carrier requires cost-sharing for enrollees receiving an emergency prescription fill as defined in WAC 284-170-470, the contract must include a clear statement dislcosing that the enrollee may be eligible to receive an emergency fill, including: Disclosures Emergency The process to obtain an emergency fill; and (Cont’d) Fills (Cont’d) Any cost sharing requirements.
Category of Provider (Cont’d) Coverage of Podiatry RCW 48.44.225 RCW 48.44.300 Issuer may not refuse to pay for covered services solely because the services were provided by a Podiatrist or Podiatric Surgeon. Experimental or Investigational Treatment 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. WAC 284-44-043 (2) The definition must include an identification of the authority or authorities which will make a determination of which services will be considered to be experimental or investigational. WAC 284-44-043 (2) If the HCSC 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
Hospitalization (EHB) (Cont’d) benefits 42 U.S.C. §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 benefits WAC Plan may include the following limitations on services in the hospitalization category: 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. State benefit requirements classified to the category State benefit requirements classified to the category (Cont’d) RCW ; WAC State benefit requirements classified to the hospitalization category are: General anesthesia and facility charges for dental procedures for those who would be at risk if the service were performed elsewhere and without anesthesia; RCW Reconstructive breast surgery resulting from a mastectomy that resulted from disease, illness or injury. WAC RCW 48.44 330(2) Coverage for all stages of one reconstructive breast reduction on the nondiseased breast to make it in size with the diseased breast after definitive reconstructive surgery on the diseased breast has been performed; and RCW Coverage for treatment of temporomandibular joint disorder. WAC 284-43-5642(3)(e)(iii) RCW ; WAC 284-43-5642 (3)(e)(iv) IF a plan covers care in a long term care facility, carrier must allow enrollee to return to the same long term care facility after hospitalization, as long as the following criteria are met:
mental health conditions and substance use disorders categorized in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including behavioral health treatment for those conditions. Required Services Required Mental Health and Substance Use Disorder Services (Cont’d) WAC Plan must include the following services, which are specifically covered by the base-benchmark plan, and classify them as mental health and substance use disorder services, including behavioral health treatment: WAC Inpatient, residential, and outpatient mental health and substance use disorder treatment, including diagnosis, partial hospital programs or inpatient services; Chemical dependency detoxification; WAC Behavioral treatment for a DSM category diagnosis; WAC Services provided by a licensed behavioral health provider for a covered diagnosis in a skilled nursing facility; WAC Prescription medication including medications prescribed during an inpatient and residential course of treatment; WAC Acupuncture treatment visits without application of the visit limitation requirements, when provided for chemical dependency; WAC 284-43 (5)(b)(ii); Benchmark Plan Mental health treatment for the following “V code” diagnoses in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM):
Therapy RCW 48.44.450(4) The contract may not exclude or limit coverage for assessment or testing to determine the amount and type of neurodevelopmental therapy needed. Language Access 45 CFR § 92.8(a) and (f)(1)(i) Contract must include, in a conspicuously visible font size, notice of the following: (Cont’d) Language Access (Cont’d) 45 CFR § 92.8(a)(1) The carrier does not discriminate on the of race, color, national origin, sex, age, or disability in its health programs and activities; 45 CFR § 92.8(a)(2) The carrier provides appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, free of charge and in a Discrimination Discrimination
WAC 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. Pediatric Vision Services (EHB) Pediatric Vision Services (EHB) (Cont’d) Requirement for Coverage WAC - 2) Plan must cover pediatric vision services as an embedded set of services. 42 USC §18021(a)(1)(B) 42 USC 18022(b)(1)(J) Plan must pediatric vision services for enrollees until at least the end of the month in which enrollees turn age nineteen. Required Pediatric Vision Services Required Pediatric Vision Services (Cont’d) WAC - 2) Plan must cover the following services in a manner substantially equal to the base benchmark plan and classify them as pediatric vision services: WAC Routine vision screening without cost sharing WAC WAC a comprehensive eye exam for children, including dilation as professionally indicated and with refraction every calendar year; WAC One pair of prescription lenses or contacts calendar year, including polycarbonate lenses and scratch resistant coating. Lenses may include single vision, conventional lined bifocal or conventional lined trifocal, or lenticular lenses;
Required Prescription Drug Services (Cont’d) Sole Available Drug Therapy WAC Plan must cover all FDA-approved prescribed drugs, medications or drug therapies that are the sole prescription drug available for a covered medical condition. No Unreasonable Restrictions on Treatment WAC Prescription drug benefit must not be such that it results or can reasonably be expected to result in an unreasonable restriction on the treatment of patients. WAC A prescription drug benefit that only covers generic drugs constitutes an unreasonable restriction on the treatment of patients. WAC Prescription drug benefit or formulary must not exclude coverage for a nonformulary drug or medication if the only formulary drug available for an enrollee's covered condition is one that the enrollee cannot tolerate or that is not clinically efficacious for the enrollee. Coverage of drugs for use WAC Plan must not exclude coverage of any FDA-approved prescription drug for a particular indication on the grounds that the drug has not been approved by the FDA for that indication, if it is recognized as effective for treatment of that indication: 450(4)(a)(i) In one of the standard reference compendia;
Prescription Drug Services (EHB) Prescription Drug Services Allowable Limitations on Prescription Drug Services (Cont’d) limitation is a floor, and an issuer may permit supplies greater than thirty days as part of its health benefit plan; WAC Teaching doses of self-administrable injectable medications may be limited to three doses per medication per lifetime. WAC Plan may restrict prescription drug coverage based on contract or plan terms and conditions that otherwise limit coverage, such as medical necessity. WAC Prescribers may use "Dispense as Written" prescriptions (prescriptions which do not allow substitution of a generic or therapeutic equivalent drug for the drug prescribed), subject to the terms and conditions of the health plan. State benefit requirements classified to this category RCW 48.43.176; RCW 48.44.440; State benefit requirements classified to the prescription drug services category include: Medical foods to treat inborn errors of metabolism (WAC RCW 48.44.315; WAC Diabetes supplies ordered by the physician (Inclusion of this benefit requirement does not bar issuer variation in diabetic supply manufacturers under its drug formulary; RCW 48.44.341; WAC Mental health prescription drugs to the extent not covered under the hospitalization or skilled nursing facility services, or mental health and substance use disorders categories. Formulary WAC An issuer's formulary is part of the prescription drug services category. The formulary filed with the commissioner must be
Prescription Drug Services (EHB) Drug Exception Process (Cont’d) 45 CFR 156.122 (c)(3)(iii) If the plan grants an external exception review of an expedited exception request, the plan must provide coverage of the drug for the duration of the exigency. WAC
Preventive and Wellness Services (EHB) (Cont’d) State Benefit Requirements Classified in Preventive and Wellness Services (Cont’d) RCW 48.44.327(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 on developmental delay, which cannot be combined with rehabilitative services for the same condition. This state benefit requirement may be classified to ambulatory patient services or mental health and substance abuse disorder including behavioral health categories; and RCW 48.44.212; WAC Treatment of congenital anomalies in newborn and dependent children. This state benefit requirement may be classified to hospitalization, ambulatory patient services or maternity and newborn categories.
Prior Authorization Transparency of Standards and Critieria RCW 48.43.016(1) If the plan imposes different authorization standards and criteria for a covered service among tiers of contracting providers of the same licensed profession, the contract must inform enrollees which tier an individual provider or group of providers is in by posting the information on its web site in a manner accessible to both enrollees and providers. RCW 48.43.016(3) Plan must post on its web site and provide upon the request of a covered person or contracting provider any prior authorization standards, criteria, or information the carrier uses for medical necessity decisions. Prior Authorization (Cont’d) Prohibited Practices Prohibited Practices (Cont’d) RCW 48.43.016(2) Plan may not require prior authorization for an evaluation and management visit or an initial treatment visit with a contracted provider in a new episode of chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapies. Plan may require a referral or prescription for these therapies, other than chiropractic. RCW 48.43.515(5) RCW 48.43.016 (6)(a) "New episode of care" means treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous ninety days and is not currently undergoing any active treatment. RCW 48.43.016 (6)(b) "Contracting provider" does not include providers employed within an integrated delivery system operated by an HCSC. Issuer must Consult with Licensed RCW 48.43.016(4) Any provider with whom the issuer consults regarding a decision to deny, limit, or terminate covered services must hold a license, certification, or registration, in good standing and
or in the application of the federal Mental Health Parity and Addiction Equity Act of 2008. on the Basis of a Health Factor Prohibited In General Discrimination on the Basis of a Health Factor Prohibited In General (Cont’d) 45 CFR 147.110(a) Individual plans must comply with 45 CFR §146.121 (which is in the CFR section otherwise only applicable to group coverage). 42 U.S.C. §300gg-4(a)(6) 45 CFR §146.121(a)(1) “Health Factor” means, in relation to an individual: Health status; Medical condition (including both physical and mental illnesses), 45 CFR §144.103 “Medical condition or condition means any condition, whether physical or mental, including, but not limited to, any condition resulting from illness, injury (whether or not the injury is accidental), pregnancy, or congenital malformation. However, genetic information is not a condition. Claims Experience Receipt of health care; Medical History; Genetic Information; Evidence of Insurability; or 45 CFR §146.121(a)(2) “Evidence of Insurability” includes conditions arising out of acts of domestic violence and participation in activities such as motorcycling, snowmobiling, vehicle riding, horseback riding, skiing, and other similar activities. Disability. 45 CFR §146.121(a)(3) The decision whether health coverage is elected for an individual (including whether the individual enrolls during special