exclusion applies uniformly to all similarly situated individuals and is not directed at individual participants based on any health factor of the participants. 45 CFR Issuer may require the satisfaction of a deductible, or §146.121 requirement if the limit or cost-sharing requirement (b)(2)(i)(C) applies uniformly to all similarly situated individuals and is not directed at individual participants based on a health factor. Discrimination 42 U.S.C. Issuer may not require a person, as a condition of enrollment or on the Basis of §300gg-4 (b) continued enrollment in the plan, to pay a premium or contribution a Health Factor 45 CFR greater than that for a similarly situated enrollee in the plan based on Prohibited - §146.121(c)(1) any health factor of the individual or a dependent of the individual. In premiums This includes discounts, rebates, payments in kind, and any other or premium differential mechanisms. contributions 45 CFR Plan may not adjust premium amount based on genetic information of 148.180(c)(1) the enrollee or a family member. 45 CFR 148.180 Manifestation of a disease or disorder in one individual also (c)(2)(ii) cannot be used as genetic information about other, covered, individuals. “Source of 45 CFR §146.121 If a plan generally provides benefits for a type of injury, the issuer Injury” (b)(2)(iii)(A) may not deny benefits otherwise provided for treatment of the injury Exclusions if the injury results from an act of domestic violence or a medical Prohibited condition (including both physical and mental health conditions). This rule applies in the case of an injury resulting from a medical condition even if the condition is not diagnosed before the injury. Utilization Requirement WAC Issuer must maintain a documented utilization review program Review to Maintain description and written clinical review criteria based on reasonable Documented medical evidence and to assure that reviews and second opinions are Program conducted in a timely manner.
exclusion applies uniformly to all similarly situated individuals and is not directed at individual participants based on any health factor of the participants. 45 CFR §146.121 (b)(2)(i)(C) Issuer may require the satisfaction of a deductible, or requirement if the limit or cost-sharing requirement applies uniformly to all similarly situated individuals and is not directed at individual participants based on a health factor. Discrimination on the Basis of a Health Factor Prohibited - In premiums or 42 U.S.C. §300gg-4 (b) 45 CFR §146.121(c)(1) Issuer may not require a person, as a condition of enrollment or continued enrollment in the plan, to pay a premium or contribution greater than that for a similarly situated enrollee in the plan based on any health factor of the individual or a dependent of the individual. This includes discounts, rebates, payments in kind, and any other premium differential mechanisms. contributions 45 CFR 148.180(c)(1) Plan may not adjust premium amount based on genetic information of the enrollee or a family member. 45 CFR 148.180 (c)(2)(ii) Manifestation of a disease or disorder in one individual also cannot be used as genetic information about other, covered, individuals. “Source of Injury” Exclusions Prohibited 45 CFR §146.121 (b)(2)(iii)(A) If a plan generally provides benefits for a type of injury, the issuer may not deny benefits otherwise provided for treatment of the injury if the injury results from an act of domestic violence or a medical condition (including both physical and mental health conditions). This rule applies in the case of an injury resulting from a medical condition even if the condition is not diagnosed before the injury. Utilization Review Requirement to Maintain Documented Program WAC Issuer must maintain a documented utilization review program description and written clinical review criteria based on reasonable medical evidence and to assure that reviews and second opinions are conducted in a timely manner.
cl-forms-19-hmo-sg-analyst-checklist.docx