average plan participant. Required RCW 48.43.510 listing of covered benefits, including RX benefits, if any, Offer of (1)(a) copy of the current formulary, if any is used Disclosure definitions of terms such as generic versus brand name, and Items policies regarding coverage of drugs, such as how they become (Cont’d) approved or taken off the formulary, and how consumers may be involved in decisions about benefits; RCW 48.43.510 listing of exclusions, reductions, and limitations to covered (1)(b) benefits, and any definition of medical necessity or coverage criteria upon which they may be based; 48.43.510 statement of the carrier's policies for protecting the (1)(c) confidentiality of health information; 48.43.510 statement of the cost of premiums and any enrollee cost-sharing (1)(d) requirements; 48.43.510 summary explanation of the carrier's review of adverse benefit (1)(e) determinations and grievance processes; 48.43.510 statement regarding the availability of a point-of-service option, (1)(f) if any, and how the option operates; and 48.43.510 convenient means of obtaining lists of participating primary care (1)(g); and specialty care providers, including disclosure of network WAC arrangements that restrict access to providers within any plan 284-170-260 network. Required RCW Contract must contain the following written information or notify 48.43.510(2)(a) Offer of the enrollee that he is entitled to it upon request: Disclosure Any documents, instruments, or other information referred to in Items (Cont’d) the medical coverage agreement; RCW A full description of the procedures to be followed by an enrollee 48.43.510(2)(b) for consulting a provider other than the primary care provider
average plan participant. Required Offer of Disclosure Items (Cont’d) RCW 48.43.510 (1)(a) listing of covered benefits, including RX benefits, if any, copy of the current formulary, if any is used definitions of terms such as generic versus brand name, and policies regarding coverage of drugs, such as how they become approved or taken off the formulary, and how consumers may be involved in decisions about benefits; RCW 48.43.510 (1)(b) listing of exclusions, reductions, and limitations to covered benefits, and any definition of medical necessity or coverage criteria upon which they may be based; 48.43.510 (1)(c) statement of the carrier's policies for protecting the confidentiality of health information; 48.43.510 (1)(d) statement of the cost of premiums and any enrollee cost-sharing requirements; 48.43.510 (1)(e) summary explanation of the carrier's review of adverse benefit determinations and grievance processes; 48.43.510 (1)(f) statement regarding the availability of a point-of-service option, if any, and how the option operates; and 48.43.510 (1)(g); WAC 284-170-260 convenient means of obtaining lists of participating primary care and specialty care providers, including disclosure of network arrangements that restrict access to providers within any plan network. Required Offer of Disclosure Items (Cont’d) RCW 48.43.510(2)(a) Contract must contain the following written information or notify the enrollee that he is entitled to it upon request: Any documents, instruments, or other information referred to in the medical coverage agreement; RCW 48.43.510(2)(b) A full description of the procedures to be followed by an enrollee for consulting a provider other than the primary care provider
cl-forms-19-hcsc-sg-analyst-checklist.docx