Prohibited 42 USC Plan may not include cost requirements with respect to the Wellness (a) preventive services listed under WAC 284-43-5642(9) (b)(i) through (iv) Limitations that are provided in-network. (WAC 284-43-5642(9)(d)) WAC The provider network must include preventive and wellness services, including chronic disease management and smoking cessation services as defined in RCW (37) and WAC (9) and (9). If these services are provided through a quit-line or help-line, the issuer must ensure that Prohibited when follow-up services are medically necessary, the enrollee will have Wellness access to sufficient information to access those services within the Limitations service area. Contracts with quit-line or help-line services are subject to (Cont’d) the same conditions and terms as other provider contracts under this section. WAC Plan must cover medically necessary neurodevelopmental therapy for any DSM diagnosis without blanket exclusions. (e.g., Plan may not limit outpatient neurodevelopmental therapy services to person’s age six and under.) RCW 48.43.043 benefit State benefit requirements classified in this category are: requirements (1)(b)(i) Colorectal cancer screening. WAC 284-43-5642(9)(e)(i) classified (1)(b)(ii) in For a covered individual who is at least 50 years old; Preventive and Less than 50 and at high risk or very high risk for colorectal cancer. Wellness RCW 48.46.275 Mammogram services, both diagnostic and screening to include Services Tomosynthesis. WAC 284-43-5642(9)(e)(ii), SB 5912 Plan can apply standard contract provisions for diagnostic mammograms applicable to other benefits such as deductible cost sharing. E.g., may apply deductible and copay requirements; and RCW Prostate cancer screening if delivered upon the recommendation of the 48.46.277(1) patient’s physician, ARNP, or Physician Assistant. WAC
Prohibited Wellness Limitations Prohibited Wellness Limitations (Cont’d) 42 USC (a) Plan may not include cost requirements with respect to the preventive services listed under WAC 284-43-5642(9) (b)(i) through (iv) that are provided in-network. (WAC 284-43-5642(9)(d)) WAC The provider network must include preventive and wellness services, including chronic disease management and smoking cessation services as defined in RCW (37) and WAC (9) and (9). If these services are provided through a quit-line or help-line, the issuer must ensure that when follow-up services are medically necessary, the enrollee will have access to sufficient information to access those services within the service area. Contracts with quit-line or help-line services are subject to the same conditions and terms as other provider contracts under this section. WAC Plan must cover medically necessary neurodevelopmental therapy for any DSM diagnosis without blanket exclusions. (e.g., Plan may not limit outpatient neurodevelopmental therapy services to person’s age six and under.) benefit requirements classified in Preventive and Wellness Services RCW 48.43.043 (1)(b)(i) (1)(b)(ii) State benefit requirements classified in this category are: Colorectal cancer screening. WAC 284-43-5642(9)(e)(i) For a covered individual who is at least 50 years old; Less than 50 and at high risk or very high risk for colorectal cancer. RCW 48.46.275 Mammogram services, both diagnostic and screening to include Tomosynthesis. WAC 284-43-5642(9)(e)(ii), SB 5912 Plan can apply standard contract provisions for diagnostic mammograms applicable to other benefits such as deductible cost sharing. E.g., may apply deductible and copay requirements; and RCW 48.46.277(1) Prostate cancer screening if delivered upon the recommendation of the patient’s physician, ARNP, or Physician Assistant. WAC
cl-forms-19-hmo-ind-analyst-checklist.docx