(1)(c)(ii) A prudent layperson possessing an average knowledge of health and medicine would have reasonably believed that they would be unable to go to an in-network emergency department in a timely fashion without serious impairment to their health. 45 CFR In addition to the in-network cost-sharing, plan can balance bill individual for the excess of §147.138(b)(3)(i) provider charges, over the minimum amount the plan is required to pay (see below). Plan complies with the cost-sharing requirements for out-of-network emergency services if 45 CFR it provides coverage at the level of the greatest of these three amounts: (1) the median rate, (2) the usual, customary and reasonable rate (or similar rate determined using the plan or issuer’s general formula for determining payments for out-of-network services, or (3) the Medicare rate. Note: See regulations for more specifics. RCW For inpatient admission, the issuer may require notification within a specified time or as soon 48.43.093 (2) thereafter as medically possible, but no less than twenty-four hours. RCW The issuer must have someone available 24/7 for preauth of post-evaluation or 48.43.093 (1)(d) services RCW The issuer may reserve the right to require transfer of a hospitalized enrollee upon stabilization. 48.43.093 (2) Enrollee may RCW 48.43.085 Does the contract allow the enrollee to freely contract to obtain any medical services outside of the obtain Services health plan on any terms the enrollee chooses? Outside the RCW 48.43.087(2) Does the contract allow the enrollee to obtain mental health services solely at his own expense IF: Plan The enrollee’s mental health care coverage is exhausted During an appeal or adverse certification process When an enrollee’s condition is excluded from coverage; or For any other clinically appropriate reason at any time. Plans with Eosinophilic Is the plan effective date after December 31, 2015? effective RCW 48.43.176 (1) Must offer coverage for medically necessary elemental formula, regardless of delivery method, dates on or after when a licensed provider with prescriptive authority diagnoses a patient with an eosinophilic Associated 1/1/2015
(1)(c)(ii) 45 CFR §147.138(b)(3)(i) 45 CFR RCW 48.43.093 (2) RCW 48.43.093 (1)(d) RCW 48.43.093 (2) A prudent layperson possessing an average knowledge of health and medicine would have reasonably believed that they would be unable to go to an in-network emergency department in a timely fashion without serious impairment to their health. In addition to the in-network cost-sharing, plan can balance bill individual for the excess of provider charges, over the minimum amount the plan is required to pay (see below). Plan complies with the cost-sharing requirements for out-of-network emergency services if it provides coverage at the level of the greatest of these three amounts: (1) the median rate, (2) the usual, customary and reasonable rate (or similar rate determined using the plan or issuer’s general formula for determining payments for out-of-network services, or (3) the Medicare rate. Note: See regulations for more specifics. For inpatient admission, the issuer may require notification within a specified time or as soon thereafter as medically possible, but no less than twenty-four hours. The issuer must have someone available 24/7 for preauth of post-evaluation or services The issuer may reserve the right to require transfer of a hospitalized enrollee upon stabilization. Enrollee may obtain Services Outside the Plan RCW 48.43.085 RCW 48.43.087(2) Does the contract allow the enrollee to freely contract to obtain any medical services outside of the health plan on any terms the enrollee chooses? Does the contract allow the enrollee to obtain mental health services solely at his own expense IF: The enrollee’s mental health care coverage is exhausted During an appeal or adverse certification process When an enrollee’s condition is excluded from coverage; or For any other clinically appropriate reason at any time. Eosinophilic Associated Plans with effective dates on or after 1/1/2015 RCW 48.43.176 (1) Is the plan effective date after December 31, 2015? Must offer coverage for medically necessary elemental formula, regardless of delivery method, when a licensed provider with prescriptive authority diagnoses a patient with an eosinophilic
checklist-forms-hmo-large-group.docx