Eligibility (Cont’d) Required 42 USC Plan must cover “emergency medical services" in a manner substantially Emergency Medical Emergency §18021(a)(1)(B) equal to the base-benchmark plan. For purposes of determining a plan's Services (EHB) Services and actuarial value, an issuer must classify as emergency medical services the (b)(1)(B) care and services related to an emergency medical condition. WAC Required WAC Plan must include the following services which are specifically covered by Emergency the base-benchmark plan and classify them as emergency services: Services WAC Ambulance transportation to an emergency room and treatment (Cont’d) provided as part of the ambulance service; WAC Emergency room and department services, supplies and treatment, including professional charges, facility costs, and outpatient charges for patient observation and medical screening exams required to stabilize a patient experiencing an emergency medical condition; WAC Prescription medications associated with an emergency medical condition, including those purchased in a foreign country. WAC Plan may not specifically exclude any services classified to the emergency medical services category or establish visit limitations on services in the Emergency (2)(b,c&d) emergency medical services category. Medical RCW 48.43.093; Plan must include the services necessary to screen and stabilize a covered Services (EHB) Required WAC person, classified to the emergency medical services category. (Cont’d) Emergency If plan restricts treatment to services by in-network providers, must include WAC a reasonable provision to emergency treatment consistent with the Services scope of the benefits regularly provided by the contract. (Cont’d)
Eligibility (Cont’d) Emergency Medical Services (EHB) Emergency Medical Services (EHB) (Cont’d) Required Emergency Services 42 USC §18021(a)(1)(B) and (b)(1)(B) Plan must cover “emergency medical services" in a manner substantially equal to the base-benchmark plan. For purposes of determining a plan's actuarial value, an issuer must classify as emergency medical services the care and services related to an emergency medical condition. WAC Required Emergency Services (Cont’d) WAC Plan must include the following services which are specifically covered by the base-benchmark plan and classify them as emergency services: WAC Ambulance transportation to an emergency room and treatment provided as part of the ambulance service; WAC Emergency room and department services, supplies and treatment, including professional charges, facility costs, and outpatient charges for patient observation and medical screening exams required to stabilize a patient experiencing an emergency medical condition; WAC Prescription medications associated with an emergency medical condition, including those purchased in a foreign country. WAC (2)(b,c&d) Plan may not specifically exclude any services classified to the emergency medical services category or establish visit limitations on services in the emergency medical services category. RCW 48.43.093; WAC WAC Plan must include the services necessary to screen and stabilize a covered person, classified to the emergency medical services category. If plan restricts treatment to services by in-network providers, must include a reasonable provision to emergency treatment consistent with the scope of the benefits regularly provided by the contract. Required Emergency Services (Cont’d)
checklist-forms-2018-hmo-individual-analyst-checklist.docx