Retrospective RCW Plan must not retrospectively deny coverage for emergency and denials 48.43.525(1) nonemergency care that had authorization under the plan’s Prohibited written policies at the time the care was rendered. RCW 48.44.465 When an authorized plan representative approves a claim for an individual prescription, the plan may not later reject that claim. Contract Cost Sharing WAC Plan must not apply cost-sharing requirements to Native Americans Standards Requirement for purchasing a health benefit plan through the exchange, whose Required Native incomes are at or below three hundred percent of federal poverty Americans level. (Cont’d) Small Group WAC A small group health benefit plan that includes the essential health Cost-Sharing (2) benefits package may not impose annual cost-sharing or deductibles that exceed the maximum annual amounts that apply to high deductible plans linked to health savings accounts, as set forth in the most recent version of IRS Publication 969, pursuant to Section 106(c)(2) of the Internal Revenue Code of 1986, and Section 1302(c)(2) of PPACA. 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 lower-value setting. Issuer may still apply applicable network requirements. Contracting RCW 48.43.085 Contract must state that the issuer may not prohibit enrollees from for Outside freely contracting to obtain any health care services outside the plan Services on any terms the enrollees choose.
Retrospective denials Prohibited RCW 48.43.525(1) Plan must not retrospectively deny coverage for emergency and nonemergency care that had authorization under the plan’s written policies at the time the care was rendered. RCW 48.44.465 When an authorized plan representative approves a claim for an individual prescription, the plan may not later reject that claim. Contract Standards Required (Cont’d) Cost Sharing Requirement for Native Americans WAC Plan must not apply cost-sharing requirements to Native Americans purchasing a health benefit plan through the exchange, whose incomes are at or below three hundred percent of federal poverty level. Small Group Cost-Sharing WAC (2) A small group health benefit plan that includes the essential health benefits package may not impose annual cost-sharing or deductibles that exceed the maximum annual amounts that apply to high deductible plans linked to health savings accounts, as set forth in the most recent version of IRS Publication 969, pursuant to Section 106(c)(2) of the Internal Revenue Code of 1986, and Section 1302(c)(2) of PPACA. 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 lower-value setting. Issuer may still apply applicable 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. network
cl-forms-19-hcsc-sg-analyst-checklist.docx