Prohibition WAC An issuer must not classify services to the rehabilitative services category if on the classification results in a limitation of coverage for therapy that is limitations medically necessary for an enrollee's treatment for cancer, chronic of medically pulmonary or respiratory disease, cardiac disease or other similar chronic necessary conditions or diseases. For purposes of this requirement, an issuer must coverage establish limitations on the number of visits and coverage of the Rehabilitative for chronic rehabilitation therapy consistent with its medical necessity and utilization and conditions review guidelines for medical/surgical benefits. (e.g., breast cancer or diseases rehabilitation therapy, respiratory therapy, and cardiac rehabilitation Habilitative Services (EHB) therapy.) Such services may be classified to the ambulatory patient or (Cont’d) hospitalization services categories for purposes of determining actuarial value.
Rehabilitative and Habilitative Services (EHB) (Cont’d) Prohibition on limitations of medically necessary coverage for chronic conditions or diseases WAC An issuer must not classify services to the rehabilitative services category if the classification results in a limitation of coverage for therapy that is medically necessary for an enrollee's treatment for cancer, chronic pulmonary or respiratory disease, cardiac disease or other similar chronic conditions or diseases. For purposes of this requirement, an issuer must establish limitations on the number of visits and coverage of the rehabilitation therapy consistent with its medical necessity and utilization review guidelines for medical/surgical benefits. (e.g., breast cancer rehabilitation therapy, respiratory therapy, and cardiac rehabilitation therapy.) Such services may be classified to the ambulatory patient or hospitalization services categories for purposes of determining actuarial value.
cl-forms-19-hmo-ind-analyst-checklist.docx