WAC Cost-sharing differentials between tiers must not be imposed on an enrollee if the sole provider or facility type or category required to deliver a covered service is not available to the enrollee in the lowest cost-sharing tier of the network. WAC All enrollees must have reasonable access to providers and facilities at the lowest cost tier of cost-sharing. WAC Provider and facility ranking program, and the criteria used to assign providers and facilities to different tiers, must not be described in plan documents so as to deceive consumers as to issuer rating practices and their effect on available benefits. WAC When a tiered network is used, issuer must provide detailed information on its web site and if requested, make available in paper form information about the tiered network including, but not limited to: WAC The providers and facilities participating in the tiered network; WAC 284-170-330 (6)(b) The selection criteria, if any, used to place the providers and facilities, but not including the results of applying those selection criteria to a particular provider or facility; WAC 284-170-330 (6)(c) The potential for providers and facilities to move from one tier to another at any time; and WAC 284-170-330 (6)(d) The tier in which each participating provider or facility is assigned. Eligibility Eligibility (Cont’d) Domestic Partner Coverage RCW 48.43.904 The spouse, marriage, marital, husband, wife, widow, widower, next of kin, and family must apply equally to state registered domestic partnerships and individuals in state registered domestic partnerships. Coverage of Dependent Child Not to RCW 48.20.420 Contract provides that coverage of a dependent child shall terminate upon attainment of a limiting age for dependent children must also provide that coverage will not be terminated due to
No Required Discounts RCW 48.43.016(5) Carrier may not require a provider to provide a discount from usual and customary rates for services not covered under a plan to which the provider is a party. Prosthodontic Services (Removable) Prosthodontic Services (Removable) (Cont’d) Required Services Required Services WAC See, also, WAC Plan must cover removable prosthodontics and prosthodontic-related procedures in a manner substantially equal to the base benchmark plan including, at a minimum: WAC One resin based partial denture; replacement covered if provided at least three years after the seat date; WAC One complete denture upper and lower and one replacement denture per lifetime after at least 5 years from the seat date; WAC Rebasing and relining of complete or partial dentures once in a 3 year period, if performed at least 6 months from the seat date. (Cont’d) Benchmark plan Occlusal guards for enrollees age 12 and Benchmark plan Adjustment and repair of dentures and bridges; Benefits need not be provided for adjustments or repairs done within one year of insertion. Provider Requirements Participating Provider Definition 284-170-130(23) “Participating provider” must be defined (whether or not this definition is set forth in the policy) consistent with the statutory and regulatory definitions: "’Participating provider’ a facility or provider who, under a contract with the health carrier or with the carrier’s contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, from the health carrier rather than from the covered person.”