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Chapter 284-43 WAC

Last Update: 7/3/14

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 accessGeneral standards.
Alternate access delivery request.
Use of subcontracted networks.
Provider directories.
Every category of health care providers.
Network reportsFormat.
Essential community providers for exchange plansDefinition.
Essential community providers for exchange plansNetwork 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 carriersGenerally.
Selection of participating providersCredentialing and unfair discrimination.
Provider contracts—Standards—Hold harmless provisions.
Provider contractsTerms and conditions of payment.
Provider contractsDispute resolution process.
Pharmacy identification cards.
Provider contractsAudit guidelines.
Participating providerFiling and approval.
Effective date.
SUBCHAPTER D
UTILIZATION REVIEW
Utilization reviewGenerally.
SUBCHAPTER E
ADVERSE BENEFIT DETERMINATION PROCESS REQUIREMENTS FOR NONGRANDFATHERED PLANS
Scope and intent.
Definitions.
Review of adverse benefit determinationsGenerally.
Explanation of right to review.
Notice and explanation of adverse benefit determinationGeneral 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 proceduresGenerally.
Procedures for review and appeal of adverse determinations.
Independent review of adverse determinations.
SUBCHAPTER G
GRIEVANCES
Definition.
Grievance processGenerally.
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 categoryPediatric oral services.
Pediatric vision services.
Plan cost-sharing and benefit substitutions and limitations.
Representations regarding coverage.
Effective date.
SUBCHAPTER IHEALTH 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.