Experimental and Investigational Services. Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing exam 10% - After deductible Not Covered Hearing diagnostic testing 10% - After deductible Not Covered Hearing aids - The benefit limit is $1,500 per hearing aid. 10% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 10% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 10% - After deductible Not Covered Human leukocyte antigen testing 10% - After deductible Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 10% - After deductible Not Covered
Experimental and Investigational Services. Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing exam 0% - After deductible 40% - After deductible Hearing diagnostic testing 0% - After deductible 40% - After deductible Hearing aids - The benefit limit is $1,500 per hearing aid. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible 40% - After deductible Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 40% - After deductible Human leukocyte antigen testing 0% - After deductible 40% - After deductible Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible 40% - After deductible Outpatient - facility 0% - After deductible 40% - After deductible In the physician’s office/in your home 0% - After deductible 40% - After deductible
Experimental and Investigational Services. 11.10.1 If the Contractor excludes or limits benefits for any services for one or more medical conditions or illnesses because such services are deemed to be experimental or investigational, the Contractor shall develop and follow policies and procedures for such exclusions and limitations. The policies and procedures shall identify the persons responsible for such decisions. The policies and procedures and any criteria for making decisions shall be made available to HCA or DSHS upon request (WACs 000-00-000, 000-00-000 and 000-00-000).
11.10.2 In making the determination, whether a service is experimental and investigational and, therefore, not a covered service, the Contractor shall consider the following:
11.10.2.1 Evidence in peer-reviewed, medical literature, as defined herein, and pre-clinical and clinical data reported to the National Institute of Health and/or the National Cancer Institute, concerning the probability of the service maintaining or significantly improving the enrollee’s length or quality of life, or ability to function, and whether the benefits of the service or treatment are outweighed by the risks of death or serious complications.
11.10.2.2 Whether evidence indicates the service or treatment is likely to be as beneficial as existing conventional treatment alternatives.
11.10.2.3 Any relevant, specific aspects of the condition.
11.10.2.4 Whether the service or treatment is generally used for the condition in the State of Washington.
11.10.2.5 Whether the service or treatment is under continuing scientific testing and research.
11.10.2.6 Whether the service or treatment shows a demonstrable benefit for the condition.
11.10.2.7 Whether the service or treatment is safe and efficacious.
11.10.2.8 Whether the service or treatment will result in greater benefits for the condition than another generally available service.
11.10.2.9 If approval is required by a regulating agency, such as the Food and Drug Administration, whether such approval has been given before the date of service.
11.10.3 Criteria to determine whether a service is experimental or investigational shall be no more stringent for Medicaid enrollees than that applied to any other members.
11.10.4 A service or treatment that is not experimental for one enrollee with a particular medical condition cannot be determined to be experimental for another enrollee with the same medical condition and similar health status.
11.10.5 A service or treatment may not be determined to be ex...
Experimental and Investigational Services. Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing exam $25 - After deductible Not Covered Hearing diagnostic testing 0%- After deductible Not Covered Hearing aids - The benefit limit is $1,500 per hearing aid. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered
