Date of Adoption: July 22, 1999.

Purpose: The rule was identified in the commissioner's regulatory improvement process as one that was out of date and should be reviewed and updated. References in the existing rule are outdated, benefit minimums established in 1987 have become ceilings and are no longer adequate to pay for increasingly effective but expensive treatment.

Citation of Existing Rules Affected by this Order: Amending WAC 284-53-010.

Statutory Authority for Adoption: RCW 48.02.060, 48.44.050, and 48.46.200.

Other Authority: RCW 48.21.160, 48.21.180, 48.21.197, 48.44.240, 48.46.350.

Adopted under notice filed as WSR 99-11-103 on May 19, 1999.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

July 22, 1999

Robert A. Harkins

Chief Deputy Commissioner

OTS-2898.3

NEW SECTION
WAC 284-53-005
Definitions.

(1) "Chronic illnesses" include, but are not limited to, heart disease, diabetes, chronic obstructive pulmonary disease, and chemical dependency.

(2) "Medically necessary" or "medical necessity," with respect to chemical dependency coverage, means indicated in the Patient Placement Criteria for the Treatment of Substance Abuse-Related Disorders II as published in 1996 by the American Society of Addiction Medicine.

(3) Other terms used in this chapter, but not specifically defined here, shall have the meanings given in WAC 284-43-130 or, if not defined there, in WAC 284-50-030.

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Contractual provisions in any policy issued or renewed on or after January 1, 2000, for chemical dependency required by RCW 48.21.180, 48.44.240, or 48.46.350 shall meet the following standards and administrative requirements.

(1) Medically necessary detoxification must be covered as an emergency medical condition according to RCW 48.43.093, and so long as a patient is not yet enrolled in other chemical dependency treatment, detoxification may not be included when calculating payments within the chemical dependency payment minimum required in this chapter.

(2) The coverage for chemical dependency shall provide payment ((toward)) for reasonable charges for any medically necessary treatment and supporting services provided to ((covered individuals)) an enrollee by an "approved treatment ((facility)) program" approved ((pursuant to)) under RCW 70.96A.020(((2) or 69.54.030, which may include medical evaluations, psychiatric evaluations, room and board (inpatient only), psychotherapy (individual and group), counseling (individual and group), behavior therapy, recreation therapy, family therapy (individual and group) for the patient and covered persons, prescription drugs prescribed by an approved treatment facility, and supplies prescribed by an approved treatment facility.  The coverage shall provide such payment whether the treatment or services are provided on an inpatient (resident) or an outpatient (nonresident) basis, except to the extent that inpatient or outpatient coverage is not provided to the individual insured for other common illnesses or disease.  Inpatient coverage shall include detoxification if detoxification is not specifically included in other contract coverage)) (3). In addition, medically necessary detoxification services may also be provided in hospitals licensed according to RCW 70.41.

(((2))) (3) Except to the extent prohibited by this ((section)) chapter, the chemical dependency coverage may be limited by provisions of the contract that are applicable to other benefits or services for other ((common)) chronic illnesses or disease generally including, but not limited to, provisions relating to ((deductibles, coinsurance and copayments)) enrollee point of service cost sharing.  However, coverage shall not be denied by reason of contract provisions which are not pertinent to the treatment of chemical dependency, such as provisions requiring a treatment ((facility)) program to have surgical facilities or approval by the joint commission on accreditation of hospitals, that there be a physician in attendance, or that the exact date of onset be known.

(((3))) (4)(a) The minimum benefits for chemical dependency treatment((,)) and supporting services ((and detoxification)) shall be ((an amount which is the lesser of five)) no less than ten thousand dollars, exclusive of ((deductibles, coinsurance and copayments,)) all enrollee point of service cost-sharing amounts in any consecutive twenty-four-month period ((or an amount equal to the benefit limit in the contract applicable to the individual insured which would normally be applied to treatment of any common major illness or disease other than chemical dependency.  The benefits may be limited to a lifetime maximum of not less than ten thousand dollars exclusive of deductibles, coinsurance and copayments, notwithstanding WAC 284-44-040(2).  For purposes of determining the limitations allowed by this subsection, with regard to all benefits except the lifetime maximum a carrier may take credit for any benefits paid by any carrier on behalf of a covered individual for chemical dependency treatment and supporting services received in an immediately preceding twenty-four-month period.  For purposes of determining the lifetime maximum allowed by this subsection, calculation must be made on either a per contract or per carrier basis except that when one group contract holder has utilized one or more carriers or plans then a carrier may take credit for amounts paid on behalf of a covered individual from January 1, 1987, onward under all past and current carriers and plans with respect to that group contract holder)).

(((4))) (b) The minimum benefit specified in this subsection must be adjusted by a carrier in any of its contracts for which a new or revised form is filed with the commissioner. The adjustment must correspond with the change in the medical care component of the consumer price index for all urban consumers for the Seattle Standard Metropolitan Statistical Area compiled by the Bureau of Labor statistics, United States Department of Labor. The base year for the computation shall be 1999.

(5) Contract provisions subject to this rule:

(a) Shall not impose waiting periods or preexisting condition limitations on chemical dependency coverage, except that a carrier may impose ((a waiting period or)) no longer than a three month preexisting condition limitation for chemical dependency treatment and supporting services to the extent that a ((waiting period or)) preexisting condition limitation is imposed for other ((common)) chronic illnesses ((or disease)).

(b) ((Shall not provide for the application of comparative statistical measures which are lacking in statistical reliability.  Because of the limited number of approved treatment facilities in this state and the diversity of methodologies and fee structures, a measure based on the application of usual, customary and reasonable charges for overall chemical dependency treatment and supporting services is not currently acceptable but comparison of costs for specific components of such treatment and supporting services may be acceptable.

(c))) Shall not deny reasonable benefits for actual treatment and services rendered solely because a course of treatment was interrupted or was not completed.

(((d))) (c) May limit coverage to specific facilities but only if the carrier provides ((one or more reasonably available and conveniently located)) or contracts for the provision of approved treatment ((facilities)) programs under RCW 70.96A.020(((2) or 69.54.030)) which alone or in combination offer both inpatient and outpatient care and which comply with network adequacy requirements established in WAC 284-43-200.  This right to limit coverage to specific facilities ((will)) permits a carrier to limit diagnosis and treatment to that rendered by itself or by a facility to which it makes referrals, but, in either case, only if the facility is or part of an approved treatment ((facility)) program under RCW 70.96A.020(((2) or 69.54.030)).

(((e))) (d) Except in the case of detoxification services, may require prenotification in all reasonable situations; may also require a second opinion if such second opinion is required under the contract generally for other ((common)) chronic illnesses ((and disease)).  Prenotification with respect to medically necessary detoxification ((in most cases would)) services is not ((be)) reasonable.

(((5))) (6) In situations where an ((insured)) enrollee is under court order to undergo a chemical dependency assessment or treatment, or in situations related to deferral of prosecution, deferral of sentencing or suspended sentencing, or in situations pertaining to motor vehicle driving rights and the Washington state department of licensing, the carrier may require the ((insured)) enrollee to furnish at the ((patient's)) enrollee's expense no less than ten and no more than thirty working days before treatment is to begin, an initial assessment of the need for chemical dependency treatment and a treatment plan, made by an individual of the ((patient's)) enrollee's choice who is a ((qualified alcoholism and/or drug treatment)) chemical dependency counselor as defined in WAC 440-22 employed by an approved treatment ((facility)) program under RCW 70.96A.020(((2) or 69.54.030)) or licensed under chapter 18.57 or 18.71 RCW to enable the carrier to make its own evaluation of medical necessity prior to scheduled treatment. Nothing in this chapter may be construed to require a carrier to pay for court ordered chemical dependency treatment that is not medically necessary, nor may anything in this chapter be construed to relieve a carrier from its obligations to pay for court ordered chemical dependency treatment when it is medically necessary.

(((6))) (7) Except as determined not to be medically necessary or otherwise specifically provided in this ((section)) chapter, contractual provisions subject to this section and the administration of such provisions shall not use definitions, predetermination procedures or other prior approval requirements, or other provisions, requirements or procedures, which ((unreasonably)) restrict access to treatment, continuity of care or payment of claims.

[Statutory Authority: RCW 48.02.060, RCW 48.44.050 and RCW 48.46.200.  87-18-050 (Order R 87-10), § 284-53-010, filed 8/31/87, effective 1/1/88; 86-18-027 (Order R 86-2), § 284-53-010, filed 8/27/86, effective 1/1/87.]