(Cont’d) Durable Does the contract or certificate define equitable Durable Medical Equipment (“DME”) Benefits in the Medical following situations? RCW Equipment 48.46.227(2); Durable medical equipment for diabetes when plan includes coverage for pharmacy services 29 USC §1185b Prostheses mastectomy RCW 70.126.020 Home Health Care benefit (as applicable under the plan’s terms), including rental of apparatus and equipment such as wheelchairs, hospital beds, respirators, splints, trusses, braces, or crutches needed for treatment. RCW 48.43.290 Coverage for DME must include the tax, or use tax calculation in payment. Emergency 42 U.S.C. Is the plan’s definition of "Emergency services" consistent with RCW 48.43.005(14) which states: Treatment Services’ means a medical screening examination, as required under section “’Emergency 1867 of the social security act (42 U.S.C. 1395dd), that is within the capability of the RCW 48.43.005 emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate that emergency medical condition, and further medical examination and treatment, to the extent they are within the capabilities of the staff and Emergency facilities available at the hospital, as are required under section 1867 of the social security act Treatment (42 U.S.C. 1395dd) to stabilize the patient. Stabilize, with respect to an emergency medical (Cont’d) condition, has the meaning given in section 1867(e)(3) of the social security act (42 U.S.C. 1395dd(e)(3))”? Is the plan’s definition of "Emergency medical condition" consistent with RCW 8.43.005(13), or 42 U.S.C. WAC 284-43-130(6), which states: Medical Condition’ the emergent and acute onset of a symptom or symptoms, “’Emergency RCW including severe pain, that would lead a prudent layperson acting reasonably to believe that a 48.43.005(13) WAC health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily
(Cont’d) Durable Medical Equipment RCW 48.46.227(2); 29 USC §1185b RCW 70.126.020 RCW 48.43.290 Does the contract or certificate define equitable Durable Medical Equipment (“DME”) Benefits in the following situations? Durable medical equipment for diabetes when plan includes coverage for pharmacy services Prostheses mastectomy Home Health Care benefit (as applicable under the plan’s terms), including rental of apparatus and equipment such as wheelchairs, hospital beds, respirators, splints, trusses, braces, or crutches needed for treatment. Coverage for DME must include the tax, or use tax calculation in payment. Emergency Treatment Emergency Treatment (Cont’d) 42 U.S.C. RCW 48.43.005 42 U.S.C. RCW 48.43.005(13) WAC Is the plan’s definition of "Emergency services" consistent with RCW 48.43.005(14) which states: “’Emergency Services’ means a medical screening examination, as required under section 1867 of the social security act (42 U.S.C. 1395dd), that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate that emergency medical condition, and further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under section 1867 of the social security act (42 U.S.C. 1395dd) to stabilize the patient. Stabilize, with respect to an emergency medical condition, has the meaning given in section 1867(e)(3) of the social security act (42 U.S.C. 1395dd(e)(3))”? Is the plan’s definition of "Emergency medical condition" consistent with RCW 8.43.005(13), or WAC 284-43-130(6), which states: “’Emergency Medical Condition’ the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily
checklist-forms-hmo-large-group.docx