Under Washington state law, certain individual/family and group plans must offer these benefits.
There are also essential health benefits that must be covered under the Affordable Care Act.
Note: Health plans are required to include these benefits. However, your medical services, supplies and prescription drugs are still subject to the plan’s medical necessity criteria.
Health benefit | Description | Plan type* |
|---|---|---|
Voluntary abortion or terminating a pregnancy may be included in a health plan's essential health benefits package. However, if a health plan provides maternity care or services, it must also provide coverage to allow | Individual /family | |
General anesthesia and related facility charges for dental procedures performed in a hospital or ambulatory surgical center must be covered for children under age seven and other specified individuals. | Group | |
Health plans covering cancer chemotherapy treatment must provide coverage for self-administered anticancer medication comparable to chemotherapy medications administered by a health care provider. | Individual/family | |
Treatment of chemical dependency must be covered in an approved treatment facility program. | Group | |
Colorectal cancer examinations and lab tests consistent with the recommendation of the U.S. Preventive Services Task Force or the federal Centers for Disease Control and Prevention must be covered. | Individual/family | |
Newborn infants must be covered from birth. The coverage must include treatment of congenital anomalies. | Individual/family | |
Health plans with comprehensive prescription coverage must cover contraceptives the same as other prescription drugs/and or devices. Effective Jan. 1, 2019, health plans must provide coverage for all prescription and over-the-counter contraceptive drugs, devices and products approved by the FDA without requiring copayments, deductibles or cost sharing. | Individual/family | |
Health plans must cover medically necessary diabetes equipment, supplies, education and training. | Individual/family | |
Health plans must provide coverage for medically necessary donor human milk for inpatient use when a licensed health care provider or board certified lactation consultant prescribes and orders it under these circumstances:
| Group (Effective Jan. 1, 2023) | |
Emergency services must be covered by health plans if a medical provider believes a patient is having an emergency. | Individual/family | |
Health insurers generally cannot exclude, deny or limit medically-necessary gender-affirming treatment. | Individual/family | |
Health plans cannot deny coverage of an injury only because it was sustained while intoxicated or under the influence of a narcotic. | Individual/family | |
Health plans must cover screening or diagnostic mammography services if recommended by a physician or advanced registered nurse practitioner. | Individual/family | |
All individual health plans must include coverage for maternity services and prescription drug coverage. | Individual | |
Health plans must cover mental health services the same way they cover medical and surgical services. | Individual/family | |
Health plans must cover neurodevelopmental therapies (occupational therapy, speech therapy, physical therapy) for enrollees age six or younger. | Group | |
Health plans must cover the formulas necessary to treat PKU. | Individual/family | |
Health plans must cover prostate cancer screenings recommend by the patient's physician, advanced registered nurse practitioner or physician assistant. | Individual/family | |
Offer employers optional coverage for TMJ, a condition that causes jaw joint and muscle pain. (Employers are not required to include this benefit in the plan.) | Group | |
Health plans must provide coverage for voluntary sterilization without requiring copayments, deductibles or cost sharing. | Individual/family | |
Health plans must provide access to women’s health services through in-network providers. Services include: maternity, reproductive health, gynecological care, general exams and preventive services. | Individual/family |
*Individual/family health plan: A plan individuals and their dependents buy directly from an insurance agent or through the state's health benefit exchange.
*Group health plan: A health insurance policy or a health care services contract (HCSC) that covers a group of employees. Health care coverage occurs under a master policy issued to the employer or other group.