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10/02/2008
Regulatory changes go into effect Jan. 1
Washington State Legislature has made changes in legislation that affect our health plans. As we continue to be committed to transforming health care in our community within legislative intent and guidelines, we will make changes to certain medical benefits effective Jan. 1, 2009.
We've also taken this opportunity to provide benefit and language revisions that add clarity for our members as they access benefits.
Below are legislative/regulatory mandate changes and language revisions that will be implemented as groups enroll or renew beginning Jan. 1, 2009. These revisions apply to all groups, except ASO groups that choose to opt out.
Legislative/Regulatory Changes
Chemical Dependency – As required by Washington State Law, the benefit for chemical dependency has increased to $14,500 every two calendar years.
*Applies to Embark, Vantage and Motivate, Asuris Northwest Health PPO 100/80/60, 80/80/50, PPO Asuris Advance 70/70/50, Asuris HSA HealthPlans, HSA Qualified PPO 80/80/60
Dependent Age – For those large groups that chose not to increase the dependent age in 2008, the dependent age limit must be raised to age 25, by Jan. 1, 2009.
*Applies to large groups only
Language Clarifications
Allowed Amount – The bold information will be added to the Preferred Plan Providers inside the Service Area, Who Have Agreements With The Company section:
"For services or supplies covered under this plan, the amount these providers have agreed to accept as payment in full pursuant to the applicable agreement between the Company and the provider. These providers agree to seek payment from the Company when they furnish covered services to Members. Members will be responsible only for any applicable deductible, Copays, Coinsurance, and charges in excess of the stated Benefit maximums, if any, and for charges for services and supplies not covered under this Contract."
*Applies to all Asuris Northwest Health PPO 100/80/60, 80/80/50, PPO Asuris Advance 70/70/50, Asuris HSA HealthPlans, HSA Qualified PPO 80/80/60, Group Dental Plans
Appeal Address Clarification – The address in the Appeals Process section will be revised to: Appeals Coordinator, P.O. Box 1271, MS C7A, Portland, Oregon 97207–1271.
*Applies to Embark, Vantage, Motivate, Aspire, Achieve and Enhance
Contract and Claims Administration
The following language will be added to clarify the member's responsibility once the lifetime or calendar year maximum benefits have been paid:
"You will be responsible for the total billed charges for benefits in excess of lifetime or calendar year maximum benefits, if any, and for charges for any other service or supply not covered under this plan, regardless of the provider rendering such service or supply."
*Applies to Embark, Vantage, Motivate, Aspire, Achieve, Enhance, Asuris Northwest Health PPO 100/80/60, 80/80/50, PPO Asuris Advance 70/70/50, Asuris HSA HealthPlans, HSA Qualified PPO 80/80/60, Group Dental Plans
Obtainment of Certificate of Creditable Coverage – In response to a request from the Department of Labor, the last sentence of the Certificate of Health Coverage paragraph will be revised to include the following contact information: P.O. Box 21267, Seattle, Washington 98111–3267.
*Applies to all Asuris Northwest Health PPO 100/80/60, 80/80/50, PPO Asuris Advance 70/70/50, Asuris HSA HealthPlans, HSA Qualified PPO 80/80/60
Mental Health Disclosures – The Mental Health Services and Your Rights section will be removed, per a recent OIC ruling.
*Applies to Embark, Vantage, Motivate, Asuris Northwest Health PPO 100/80/60, 80/80/50, PPO Asuris Advance 70/70/50, Asuris HSA HealthPlans, HSA Qualified PPO 80/80/60
Prescription Benefits MAC A and MAC B Penalty – Clarification is needed to further explain the intent of the administration of the difference in price between generic and brand. The bold language will be added: The difference is calculated at the time of purchase based upon the difference in price between the equivalent Generic medication and the applicable Brand Name Medication, in addition to the Copayment and/or Coinsurance (as applicable).
*Applies to Embark, Vantage and Motivate
Reimbursement Examples – The Reimbursement Examples by Category will be revised to use 80/80/80 as an example. The examples will be revised to reflect the proper amounts of the 80% coinsurance in each category.
*Applies to Vantage Only
Women's Health and Cancer Rights – In response to a request from the Department of Labor, the Women's Health and Cancer Rights notice will be included in the booklet.
*Applies to all Asuris Northwest Health PPO 100/80/60, 80/80/50, PPO Asuris Advance 70/70/50, Asuris HSA HealthPlans, HSA Qualified PPO 80/80/60
General Exclusions
Benefits Not Stated –
The following exclusion will be removed, to retain consistency amongst our new product contracts:
"When a Member receives a non–Covered service or supply at the same time as a Covered Service, We will consider only the portion of charges relating to the Covered Service eligible for payment."
*Applies to Embark, Vantage, Aspire, Achieve and Enhance
Oral Surgery –
The following exclusion will be revised, to retain consistency amongst our new product contracts, resulting in no changes to our administration:
"Oral surgery treating any fractured jaw, and orthognathic surgery. By "orthognathic surgery," We mean surgery to manipulate facial bones, including the jaw, in patients with facial bone abnormalities performed to restore the proper anatomic and functional relationship of the facial bones."
*Applies Aspire, Achieve and Enhance
Orthognathic Surgery –
The following exclusion has been revised to clarify those conditions that are not intended to be excluded from coverage:
"Services and supplies for orthognathic surgery. By "orthognathic surgery" We mean surgery to manipulate facial bones, including the jaw, in patients with facial bone abnormalities resulting from injury, congenital anomaly or abnormal development to restore the proper anatomic and functional relationship of the facial bones. This exclusion does not apply to orthognathic surgery due to a temporomandibular joint disorder, injury, sleep apnea or congenital anomaly."
*Applies to Embark, Vantage and Motivate
If you have questions, please talk to your Asuris Sales contact.
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