Subject: Women's Direct Access
Date: November 30, 1999
The Office of the Insurance Commissioner (OIC) is issuing this Technical Assistance Advisory to assist carriers in complying with RCW 48.42.100, governing women's direct access to women's health care services, and WAC 284-43-250, implementing that statute.
1. Coverage for incidental services provided by women's health care practitioner.
A woman has direct access to appropriate covered women's health care services from her women's health care practitioner "without the necessity of prior referral from another type of health care practitioner." RCW 48.42.100 (5)(a). Women's health care services include but are not limited to "maternity care; reproductive health services; gynecological care; [and] general examination[s]...." RCW 48.42.100(3).
WAC 284-43-250(1) provides: "Women's health care services also include any appropriate health care service for other health problems, discovered and treated during the course of a visit to a women's health care practitioner for a women's health care service, which is within the practitioner's scope of practice."
Consequently, when a woman self-refers to her women's health care practitioner for women's health care services, the carrier cannot restrict coverage to female-specific diagnostic codes. The carrier is required to provide coverage for other covered medically necessary and appropriate health care services discovered and treated during the course of that visit within her practitioner's scope of practice.
As an example: A woman self-refers to her women's health care provider for women's health care services. During the examination, the provider determines that the patient is suffering from a urinary tract infection. The statute and regulations require that the carrier provide coverage for diagnosis and treatment of both the women's health care portion of the visit and her urinary tract infection.
Of course, carriers may apply policies against "upcoding" and "unbundling" of diagnostic and procedure codes.
2. Coverage for institutional or related charges as a result of treatment by a women's health care practitioner.
WAC 284-43-250 (3)(a) provides that: "All health carriers shall permit each female policyholder, subscriber, enrolled participant, or beneficiary... to directly access the types of women's health care practitioners identified in RCW 48.42.100(2), for appropriate covered women's health care services without prior referral from another health care practitioner." The provider network for each health plan must include "sufficient number of each type of practitioner" included in the definition of women's health practitioner to "ensure that enrollees can exercise their right of direct access." WAC 284-43-250(3). Women's health care services include but are not limited to "maternity care; reproductive health services; [and] gynecological services…." RCW 48.43.100(3).
Women's health care services are not limited to office based services and may include medically necessary covered services appropriately rendered by a women's health care practitioner in other settings.
As an example: A patient's women's health care practitioner has privileges at, and is affiliated with, a clinic which refers patients to Hospital A. Her selected primary care provider has privileges at, and is affiliated with, a clinic that refers its patients to Hospital B. Both hospitals are part of the network available to the patient under her health plan. She self-refers to her women's health care practitioner. Direct access allows her to receive women's health care services from her women's health care practitioner at Hospital A without being admitted by her primary care provider or a referral for admission from her primary care provider.
Of course, all otherwise applicable health plan requirements for preauthorization or other prior approval (e.g., based on medical necessity) by the carrier prior to hospitalization or to specific procedures would continue to apply.
Should you have any questions or concerns about women's direct access to care, please contact: Deputy Commissioner for Legal Affairs Jeff Coopersmith, phone (360) 753-7302; Staff Counsel Mary Cotter, phone (360) 664-2093; or Chief Managed Care Investigator Chris Daugherty, phone (360) 664-2531.
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.