Prescription Drugs (Cont’d) Definition of 42 USC §18021 Plan must cover "preventive and wellness services, including chronic Preventive and Wellness Preventive (a)(1)(B); disease management" in a manner substantially equal to the base Services, and Wellness 42 USC benchmark plan. For purposes of determining a plan's actuarial value, Including Services, 18022(b)(1)(I); an issuer must classify as preventive and wellness services, including Chronic Including WAC chronic disease management, the services that identify or prevent the Disease Chronic onset or worsening of disease or disease conditions, illness or injury, Management Disease often asymptomatic; services that assist in the multidisciplinary (EHB) Management management and treatment of chronic diseases; and services of particular preventative or early identification of disease or illness of value to specific populations, such as women, children and seniors. Preventive WAC Requirements If the plan does not have in its network a provider who can perform the and Wellness for Preventive particular service, then the plan must cover the item or service when Services, WAC and Wellness performed by an out-of-network provider and must not impose Including Services with respect to the item or service. Chronic WAC Plan must not limit sex-specific recommended preventive services Disease based on an individual's sex assigned at birth, gender identity or Management recorded gender. If a provider determines that a sex-specific (EHB) recommended preventive service is medically appropriate for an (Cont’d) individual, and the individual otherwise satisfies the coverage requirements, the plan must provide coverage without cost-sharing.
Prescription Drugs (Cont’d) Preventive and Wellness Services, Including Chronic Disease Management (EHB) Preventive and Wellness Services, Including Chronic Disease Management (EHB) (Cont’d) Definition of Preventive and Wellness Services, Including Chronic Disease Management 42 USC §18021 (a)(1)(B); 42 USC 18022(b)(1)(I); WAC Plan must cover "preventive and wellness services, including chronic disease management" in a manner substantially equal to the base benchmark plan. For purposes of determining a plan's actuarial value, an issuer must classify as preventive and wellness services, including chronic disease management, the services that identify or prevent the onset or worsening of disease or disease conditions, illness or injury, often asymptomatic; services that assist in the multidisciplinary management and treatment of chronic diseases; and services of particular preventative or early identification of disease or illness of value to specific populations, such as women, children and seniors. Requirements for Preventive and Wellness Services WAC WAC If the plan does not have in its network a provider who can perform the particular service, then the plan must cover the item or service when performed by an out-of-network provider and must not impose with respect to the item or service. WAC Plan must not limit sex-specific recommended preventive services based on an individual's sex assigned at birth, gender identity or recorded gender. If a provider determines that a sex-specific recommended preventive service is medically appropriate for an individual, and the individual otherwise satisfies the coverage requirements, the plan must provide coverage without cost-sharing.
checklist-forms-2018-hcsc-small-group-analyst-checklist.docx