Prescription Drug Services (EHB) (Cont’d) Preventive and Definition of 42 USC Plan must cover "preventive and wellness services, including Wellness Preventive and §18021 chronic disease management" in a manner substantially equal to Services, Wellness (a)(1)(B); the base-benchmark plan. For purposes of determining a plan's Services, 42 USC actuarial value, an issuer must classify as preventive and wellness Including Chronic Including 18022(b)(1)(I); services, including chronic disease management, the services that Disease Chronic WAC identify or prevent the onset or worsening of disease or disease Management Disease conditions, illness or injury, often asymptomatic; services that (EHB) Management assist in the multidisciplinary management and treatment of chronic diseases; and services of particular preventative or early identification of disease or illness of value to specific populations, such as women, children and seniors. WAC Requirements If the plan does not have in its a provider who can perform the particular service, then the plan must cover the (9)(a); WAC item or service when performed by an out-of-network provider Preventive and Requirements and must not impose cost-sharing with respect to the item or Wellness (Cont’d) service. Services, WAC Plan must not sex-specific recommended preventive Including services based on an individual's sex assigned at birth, gender Chronic (9)(a) identity or recorded gender. If a provider determines that a Disease recommended preventive service is medically Management appropriate for an individual, and the individual otherwise (EHB) satisfies the coverage requirements, the plan must provide (Cont’d) coverage without cost-sharing.
Prescription Drug Services (EHB) (Cont’d) Preventive and Wellness Services, Including Chronic Disease Management (EHB) Preventive and Wellness Services, Including Chronic Disease Management (EHB) (Cont’d) Definition of Preventive and Wellness Services, Including Chronic Disease Management 42 USC §18021 (a)(1)(B); 42 USC 18022(b)(1)(I); WAC Plan must cover "preventive and wellness services, including chronic disease management" in a manner substantially equal to the base-benchmark plan. For purposes of determining a plan's actuarial value, an issuer must classify as preventive and wellness services, including chronic disease management, the services that identify or prevent the onset or worsening of disease or disease conditions, illness or injury, often asymptomatic; services that assist in the multidisciplinary management and treatment of chronic diseases; and services of particular preventative or early identification of disease or illness of value to specific populations, such as women, children and seniors. Requirements Requirements (Cont’d) WAC (9)(a); WAC If the plan does not have in its a provider who can perform the particular service, then the plan must cover the item or service when performed by an out-of-network provider and must not impose cost-sharing with respect to the item or service. WAC (9)(a) Plan must not sex-specific recommended preventive services based on an individual's sex assigned at birth, gender identity or recorded gender. If a provider determines that a recommended preventive service is medically appropriate for an individual, and the individual otherwise satisfies the coverage requirements, the plan must provide coverage without cost-sharing.