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Chapter 284-43 WAC

Last Update: 11/19/14

HEALTH CARRIERS AND HEALTH PLANS

WAC Sections

SUBCHAPTER A
GENERAL PROVISIONS
Purpose.
Applicability and scope.
Compliance with state and federal laws.
Definitions.
SUBCHAPTER B
HEALTH CARE NETWORKS
Network access—General standards.
Alternate access delivery request.
Use of subcontracted networks.
Provider directories.
Every category of health care providers.
Network reports—Format.
Essential community providers for exchange plans—Definition.
Essential community providers for exchange plans—Network access.
Tiered provider networks.
Assessment of access.
Issuer standards for women's right to directly access certain health care practitioners for women's health care services.
Covered person's access to providers.
Hospital emergency service departments and practice groups.
Standards for temporary substitution of contracted network providers—"Locum tenens" providers.
Rule concerning contracted network providers called to active duty military service.
SUBCHAPTER C
PROVIDER CONTRACTS AND PAYMENT
Provider and facility contracts with health carriers—Generally.
Selection of participating providers—Credentialing and unfair discrimination.
Provider contracts—Standards—Hold harmless provisions.
Provider contracts—Terms and conditions of payment.
Provider contracts—Dispute resolution process.
Pharmacy identification cards.
Provider contracts—Audit guidelines.
Participating provider—Filing and approval.
Effective date.
SUBCHAPTER D
UTILIZATION REVIEW
Utilization review—Generally.
SUBCHAPTER E
ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS
Scope and intent.
Definitions.
Review of adverse benefit determinations—Generally.
Explanation of right to review.
Notice and explanation of adverse benefit determination—General requirements.
Electronic disclosure and communication by carriers.
Internal review of adverse benefit determinations.
Exhaustion of internal review remedies.
Notice of internal review determination.
Expedited review.
Concurrent expedited review of adverse benefit determinations.
External review of adverse benefit determinations.
SUBCHAPTER F
GRANDFATHERED HEALTH PLAN APPEAL PROCEDURES
Application of subchapter F.
Grievance and complaint procedures—Generally.
Procedures for review and appeal of adverse determinations.
Independent review of adverse determinations.
SUBCHAPTER G
GRIEVANCES
Definition.
Grievance process—Generally.
SUBCHAPTER H
HEALTH PLAN BENEFITS
Recognizing the exercise of conscience by purchasers of basic health plan services and ensuring access for all enrollees to such services.
Coverage for pharmacy services.
General prescription drug benefit requirements.
Prescription drug benefit design.
Formulary changes.
Cost-sharing for prescription drugs.
Health plan disclosure requirements.
Unfair practice relating to health coverage.
Prescription drug benefit disclosures.
Anticancer medication.
Purpose and scope.
Clinical trials.
Definitions.
Medical necessity determination.
Essential health benefits package benchmark reference plan.
Plan design.
Essential health benefit categories.
Essential health benefit category—Pediatric oral services.
Pediatric vision services.
Plan cost-sharing and benefit substitutions and limitations.
Representations regarding coverage.
Effective date.
SUBCHAPTER I—HEALTH PLAN RATES
Authority and purpose.
Applicability and scope.
Definitions.
Demonstration that benefits provided are not reasonable in relation to the amount charged for a contract per RCW 48.44.020 and 48.46.060.
When a carrier is required to file.
General contents of all filings.
Contents of individual and small group filings.
Experience records.
Evaluating experience data.
Summary for individual and small group contract filings.
Summary for group contract filings other than small group contract filings.
SUBCHAPTER K
MENTAL HEALTH AND SUBSTANCE USE DISORDER
Scope and intentParity in mental health and substance use disorder benefits.
Definitions.
Classification of benefits.
Measuring health plan benefitsFinancial requirements and quantitative treatment limitations.
Measuring health plan benefitsNonquantitative treatment limitations.
Prohibited exclusions.
Required disclosures.
Compliance and reporting of quantitative parity analysis.