Reasonable WAC Plan may include reasonable medical management to control costs, Medical including promoting the use of appropriate, high value preventive Management services, providers and settings. Plan must permit waiver of an otherwise applicable copayment for a service that is tied to one setting but not the preferred high-value setting, if the enrollee's provider determines that it would be medically inappropriate to have the service provided in the setting. Issuer may still apply applicable in-network requirements. Contracting RCW 48.43.085 Contract must state that the issuer may not prohibit enrollees from freely for Outside contracting to obtain any health care services outside the plan on any Services terms the enrollees choose. No Annual or WAC An issuer must not impose annual or lifetime dollar limits on an essential Lifetime Dollar health benefit, other than those specifically permitted under WAC Limits 284-43-5702 and 284-43-5782. Discretionary RCW Contract must not purport to give the HMO or any designee authority to 48.46.060(2) Clauses make a decision on the contract, or coverage or claims thereunder, is Prohibited final and binding on the enrollee. Discretionary RCW Contract may not contain a “discretionary clause” that purports to Clauses 48.46.060(3)(a) reserve discretion to a carrier or its designees to interpret the contract or Prohibited decide eligibility for benefits, or requires deference to such (Cont’d) interpretations or decisions. WAC Specific prohibited provisions: That the carrier's interpretation of the terms of the contract is binding; WAC That the carrier's decision regarding eligibility or continued receipt of benefits is binding;
Reasonable Medical Management WAC Plan may include reasonable medical management to control costs, including promoting the use of appropriate, high value preventive services, providers and settings. Plan must permit waiver of an otherwise applicable copayment for a service that is tied to one setting but not the preferred high-value setting, if the enrollee's provider determines that it would be medically inappropriate to have the service provided in the setting. Issuer may still apply applicable in-network requirements. Contracting for Outside Services RCW 48.43.085 Contract must state that the issuer may not prohibit enrollees from freely contracting to obtain any health care services outside the plan on any terms the enrollees choose. No Annual or Lifetime Dollar Limits WAC An issuer must not impose annual or lifetime dollar limits on an essential health benefit, other than those specifically permitted under WAC 284-43-5702 and 284-43-5782. Discretionary Clauses Prohibited Discretionary Clauses Prohibited (Cont’d) RCW 48.46.060(2) Contract must not purport to give the HMO or any designee authority to make a decision on the contract, or coverage or claims thereunder, is final and binding on the enrollee. RCW 48.46.060(3)(a) Contract may not contain a “discretionary clause” that purports to reserve discretion to a carrier or its designees to interpret the contract or decide eligibility for benefits, or requires deference to such interpretations or decisions. WAC Specific prohibited provisions: That the carrier's interpretation of the terms of the contract is binding; WAC That the carrier's decision regarding eligibility or continued receipt of benefits is binding;
cl-forms-19-hmo-ind-analyst-checklist.docx