Requirement WAC Such substitution must be made only with the consent of the Alternative to Hospitalization to cover home insured and on the recommendation of the insured's attending (Cont’d) care in Lieu of physician or licensed provider that such services will adequately meet the insured patient's needs. The decision to substitute less expensive or less intensive services shall be determined based (Cont’d) on the medical needs of the individual enrollee. WAC HCSC may require that home health agencies or similar alternative care providers have written treatment plans which are approved by the enrollee’s attending physician or other licensed provider. WAC Coverage may be limited to no less than the maximum benefits which would be payable for hospital or other institutional expenses under the contract, and may include all deductibles and coinsurances which would be payable by the insured under the hospital or other institutional expense coverage of the insured's contract. Ambulatory General Plan must cover "ambulatory patient services" substantially equal Patient Ambulatory 42 USC to the base-benchmark plan. In determining AV, an issuer must Services (EHB) §18021(a)(1)(B); Patient classify as "ambulatory patient services" those medically necessary 42 Services USC services delivered to enrollees in settings other than a hospital or 18022(b)(1)(A) Requirements skilled nursing facility, which are generally recognized and accepted for diagnostic or therapeutic purposes to treat illness or injury. WAC 284-43-5642(1). WAC 284-43- Plan must cover the following, which are specifically covered by the base-benchmark plan, and classify them as ambulatory patient services: Home and outpatient dialysis services;
Alternative to Hospitalization (Cont’d) Requirement to cover home care in Lieu of (Cont’d) WAC Such substitution must be made only with the consent of the insured and on the recommendation of the insured's attending physician or licensed provider that such services will adequately meet the insured patient's needs. The decision to substitute less expensive or less intensive services shall be determined based on the medical needs of the individual enrollee. WAC HCSC may require that home health agencies or similar alternative care providers have written treatment plans which are approved by the enrollee’s attending physician or other licensed provider. WAC Coverage may be limited to no less than the maximum benefits which would be payable for hospital or other institutional expenses under the contract, and may include all deductibles and coinsurances which would be payable by the insured under the hospital or other institutional expense coverage of the insured's contract. Ambulatory Patient Services (EHB) General Ambulatory Patient Services Requirements 42 USC §18021(a)(1)(B); 42 USC 18022(b)(1)(A) Plan must cover "ambulatory patient services" substantially equal to the base-benchmark plan. In determining AV, an issuer must classify as "ambulatory patient services" those medically necessary services delivered to enrollees in settings other than a hospital or skilled nursing facility, which are generally recognized and accepted for diagnostic or therapeutic purposes to treat illness or injury. WAC 284-43-5642(1). WAC Plan must cover the following, which are specifically covered by the base-benchmark plan, and classify them as ambulatory patient services: Home and outpatient dialysis services; 284-43-