(1) Issuers must not exclude any category of
providers licensed by the state of Washington who provide health care services
or care within the scope of their practice for services covered as essential
health benefits, as defined in WAC
284-43-5640 and
284-43-5642 and
RCW
48.43.715, for individual and small group
plans; and as covered by the basic health plan, as defined in
RCW
48.43.005(4), for plans
other than individual and small group.
For individual and small group plans, the issuer must not
exclude a category of provider who is licensed to provide services for a
covered condition, and is acting within the scope of practice, unless such
services would not meet the issuer's standards pursuant to
RCW
48.43.045(1)(a). For
example, if the issuer covers outpatient treatment of lower back pain as part
of the essential health benefits, any category of provider that provides
cost-effective and clinically efficacious outpatient treatment for lower back
pain within its scope of practice and otherwise abides by standards pursuant to
RCW
48.43.045(1)(a) must not be
excluded from the network.
(2)
RCW
48.43.045(1)(a) permits
issuers to require providers to abide by certain standards. These standards may
not be used in a manner designed to exclude categories of providers
unreasonably. For example, issuers must not decide that a particular category
of provider can never render any cost-effective or clinically efficacious
services and thereby exclude that category of provider completely from health
plans on that basis.
(3) Health
plans are not prohibited by this section from placing reasonable limits on
individual services rendered by specific categories of providers based on
relevant information or evidence of the type usually considered and relied upon
in making determinations of cost-effectiveness or clinical efficacy. However,
health plans must not contain unreasonable limits, and must not include limits
on the type of provider permitted to render the covered service unless such
limits comply with
RCW
48.43.045(1)(a).
(4) This section does not prohibit health
plans from using restricted networks. Issuers offering plans with restricted
networks may select the individual providers in any category of provider with
whom they will contract or whom they will reimburse. An issuer is not required
by
RCW
48.43.045 or this section to accede to a
request by any individual provider for inclusion in any network for any health
plan.
(a) Health plan networks that use
"gatekeepers" or "medical homes" for access to specialist providers may use
them for access to specified categories of providers.
(b) For purposes of this section:
(i) "Gatekeeper" means requiring a referral
from a primary care or direct access provider or practitioner to access
specialty or in-patient services.
(ii) "Medical home" means a team based health
care delivery model for patient centered primary care that provides
comprehensive and continuous medical care to patients with the goal of
obtaining maximized health outcomes as modified and updated by the Agency for
Healthcare Research and Quality, the U.S. Department of Health and Human
Services (HRSA), and other state and federal agencies.
(5) Issuers must not offer
coverage for health services for certain categories of providers solely as a
separately priced optional benefit.
(6) The insurance commissioner may grant
reasonable temporary extensions of time for implementation of
RCW
48.43.045 or this section, or any part
thereof, for good cause shown.
Notes
Wash. Admin. Code §
284-170-270
Decodified
by
WSR
16-07-144, Filed 3/23/2016, effective
4/23/2016.
Recodified from § 284-43-9975.
Amended by
WSR
16-14-106, Filed 7/6/2016, effective
8/6/2016
