Alternative to Requirement to WAC Such substitution must be made only with the consent of the insured cover home and on the recommendation of the insured's attending physician or Hospitalization (Cont’d) care in Lieu of licensed provider that such services will adequately meet the insured Hospitalization patient's needs. The decision to substitute less expensive or less (Cont’d) intensive services shall be determined based on the medical needs of the individual enrollee. WAC HCSC may require that home health agencies or similar alternative care providers have written treatment plans which are approved by the enrollee’s attending physician or other licensed provider. WAC Coverage may be limited to no less than the maximum benefits which would be payable for hospital or other institutional expenses under the contract, and may include all deductibles and coinsurances which would be payable by the insured under the hospital or other institutional expense coverage of the insured's contract. Ambulatory 42 USC General §18021 Plan must cover "ambulatory patient services" substantially equal to the Patient Services (a)(1)(B); Ambulatory 42 base benchmark plan. In determining AV, an issuer must classify as (EHB) Patient USC 18022 Services "ambulatory patient services" those medically necessary services (b)(1)(A); Requirements WAC delivered to enrollees in settings other than a hospital or skilled nursing 284-43-5642(1) facility, which are generally recognized and accepted for diagnostic or therapeutic purposes to treat illness or injury. WAC 284-43- Plan must cover the following, which are specifically covered by the base benchmark plan, and classify them as ambulatory patient services: Home and outpatient dialysis services; WAC Hospice and home health care, including skilled nursing care as an alternative to hospitalization consistent with state law.
Alternative to Hospitalization (Cont’d) Requirement to cover home care in Lieu of Hospitalization (Cont’d) WAC Such substitution must be made only with the consent of the insured and on the recommendation of the insured's attending physician or licensed provider that such services will adequately meet the insured patient's needs. The decision to substitute less expensive or less intensive services shall be determined based on the medical needs of the individual enrollee. WAC HCSC may require that home health agencies or similar alternative care providers have written treatment plans which are approved by the enrollee’s attending physician or other licensed provider. WAC Coverage may be limited to no less than the maximum benefits which would be payable for hospital or other institutional expenses under the contract, and may include all deductibles and coinsurances which would be payable by the insured under the hospital or other institutional expense coverage of the insured's contract. Ambulatory Patient Services (EHB) General Ambulatory Patient Services Requirements 42 USC §18021 (a)(1)(B); 42 USC 18022 (b)(1)(A); WAC 284-43-5642(1) Plan must cover "ambulatory patient services" substantially equal to the base benchmark plan. In determining AV, an issuer must classify as "ambulatory patient services" those medically necessary services delivered to enrollees in settings other than a hospital or skilled nursing facility, which are generally recognized and accepted for diagnostic or therapeutic purposes to treat illness or injury. WAC Plan must cover the following, which are specifically covered by the base benchmark plan, and classify them as ambulatory patient services: Home and outpatient dialysis services; WAC Hospice and home health care, including skilled nursing care as an alternative to hospitalization consistent with state law. 284-43-
checklist-forms-2018-hcsc-small-group-analyst-checklist.docx