Prohibited WAC Contract must specifically explain any uniformly applied Limitations limitation on the scope, visit number, or duration of a benefit, and state whether the uniform limitation is subject to adjustment based on the specific treatment requirements of the patient. WAC Contract must not unreasonably benefits to a specified period of time. (e.g., cannot have a provision that services for a particular condition will be covered only for one year without regard to the amount of the benefits paid or provided.) Prohibited WAC Contract must not contain an exclusion that unreasonably Limitations restricts access to medically necessary services for populations (Cont’d) with special needs including, but not limited to, a chronic Contract condition caused by illness or injury, either acquired or Standards congenital. Required WAC Plan must not create a risk of biased selection based on health (Cont’d) status. (b) The benefits within an EHB category must not be so limited that the coverage for the category is not a meaningful benefit. Right to legal WAC In the case of controversy arising out of the contract, a subscriber or arbitration Firestone must not be denied the to have the controversy determined proceedings v. Bruch by legal or arbitration proceedings. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) No required WAC A contract must not contain any provision which requires a purchase of subscriber to purchase a "monthly treatment order." Plan cannot monthly require enrollee to pay a special charge, distinct from the treatment fees required of all enrollees and cost sharing amounts, order in order to obtain advance authorization for treatment or services.
Contract Standards Required (Cont’d) Prohibited Limitations WAC Contract must specifically explain any uniformly applied limitation on the scope, visit number, or duration of a benefit, and state whether the uniform limitation is subject to adjustment based on the specific treatment requirements of the patient. WAC Contract must not unreasonably benefits to a specified period of time. (e.g., cannot have a provision that services for a particular condition will be covered only for one year without regard to the amount of the benefits paid or provided.) Prohibited Limitations (Cont’d) WAC Contract must not contain an exclusion that unreasonably restricts access to medically necessary services for populations with special needs including, but not limited to, a chronic condition caused by illness or injury, either acquired or congenital. WAC (b) Plan must not create a risk of biased selection based on health status. The benefits within an EHB category must not be so limited that the coverage for the category is not a meaningful benefit. Right to legal or arbitration proceedings WAC Firestone v. Bruch In the case of controversy arising out of the contract, a subscriber must not be denied the to have the controversy determined by legal or arbitration proceedings. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) No required purchase of monthly treatment order WAC A contract must not contain any provision which requires a subscriber to purchase a "monthly treatment order." Plan cannot require enrollee to pay a special charge, distinct from the fees required of all enrollees and cost sharing amounts, in order to obtain advance authorization for treatment or services.