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    v1.0.28
    OpenPayerPolicy UpdatesPreventive Services & ScreeningWashington OIC EHB changes — Coverage Update | Ope…
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    ModifiedWashington Office of the Insurance CommissionerPolicy N/A

    Essential Health Benefits expansion — Coverage Criteria

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    This document describes OIC updates to Washington's Essential Health Benefits benchmark for plan years beginning January 1, 2026, adding or modifying benefits such as hearing aids, donor human milk, artificial insemination, rehabilitation, routine foot care, acupuncture, and pediatric dental limits for individual and small group non-grandfathered plans.

    Policy Summary
    PayerWashington Office of the Insurance Commissioner
    PolicyEssential Health Benefits expansion — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeMultiple additions and revisions to EHB benefits for PY2026
    Effective DateDec 10, 2024
    Next Review DateN/A
    Key ActionObtain and document a preliminary infertility evaluation and diagnosis when required to support coverage for artificial insemination benefits.
    SourceLink
    POLICY UPDATE CHANGES

    Adds hearing aid benefit including an annual hearing exam and one hearing aid per ear every three years with no dollar limit.

    Adds coverage for donor human milk for medically necessary inpatient use for infants who meet specified criteria.

    Adds artificial insemination in vivo benefit, covering placement of sperm into cervix or uterus and simple sperm preparation.

    Clarifies that preliminary infertility evaluation and diagnosis is covered and may be required prior to artificial insemination coverage.

    Modifies rehabilitative services to cover neurodevelopmental therapy and clarifies combined outpatient rehabilitative therapy visits are limited to 25 per member per calendar year.

    Preliminary infertility evaluation and diagnosis is covered and may be required prior to receiving artificial insemination benefit coverage.

    Outpatient rehabilitative speech, occupational, and physical therapy services combined are limited to a maximum of 25 visits per member per calendar year.

    Routine foot care services are expanded to include treatment of corns and calluses, trimming of nails, and foot care appliances for preventive care when medically necessary (previously limited to people with diabetes).

    The yearly visit limitation for acupuncture care is removed.

    Removes age limit for permanent indirect crowns and covers an indirect crown in a five-year period, per tooth, for permanent anterior teeth that are fully erupted.

    Actuarial projected allowed cost impacts for recommended benefits: Hearing aids 0.07%, Human donor milk 0.02%, Artificial insemination in vivo 0.01%.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    2026-01-01EHB effective date
    8EHB changes listed
    25Rehab visit limit
    3yHearing aid freq
    0.07%Projected impact — Hearing Aids

    Coverage Criteria and Medical Necessity

    Hearing Aids

    Covered when ALL of the following are met:

    Hearing aid benefit: Includes an annual hearing exam and one hearing aid per ear with hearing loss every three years; no dollar limit.one hearing aid per ear every 3 years

    Applies as of 1/1/2026; large group policies with a hearing aid benefit may not impose a dollar limit.

    Donor Human Milk

    Covered when ALL of the following are met:

    Donor human milk inpatient coverage: Medically necessary donor human milk in an inpatient setting for an infant who is medically or physically unable to receive maternal human milk.infant must meet at least one criterion in RCW 48.43.815

    Coverage limited to infants meeting statutory criteria.

    Artificial Insemination / Infertility

    Covered when ALL of the following are met:

    In vivo artificial insemination: Covers placement of sperm into the cervix or uterus to achieve pregnancy and includes simple sperm preparation such as sperm washing and isolation.may require preliminary infertility evaluation and diagnosis prior to coverage

    Does not include donor sperm or eggs, or services related to procuring or storing these materials; preliminary infertility evaluation and diagnosis is covered and may be required prior to artificial insemination benefit coverage.

    Rehabilitation Services

    Covered when ALL of the following are met:

    Neurodevelopmental and rehabilitation coverage: Covers neurodevelopmental therapy and rehabilitation services to treat the same condition.combined limit = 25 visits/year

    Outpatient rehabilitative speech, occupational, and physical therapy services combined are limited to a maximum of 25 visits per Member per Calendar Year.

    Expanded covered services and limits

    Covered or expanded when the stated conditions are met:

    Infertility evaluation prerequisite: Preliminary infertility evaluation and diagnosis is covered and may be required prior to receiving artificial insemination benefit coverage.

    Providers should document evaluation and diagnosis if required by the plan.

    Rehabilitative services combined limit: Neurodevelopmental therapy and rehabilitation services are covered to treat the same condition; outpatient rehabilitative speech, occupational, and physical therapy services combined are limited to a maximum of 25 visits per Member per Calendar Year.25 visits/year combined
    Routine foot care (expanded): Routine foot care services expanded to include treatment of corns and calluses, trimming of nails, and foot care appliances for preventive care when medically necessary (previously limited to people with diabetes).medical necessity required

    Benefits for donor sperm or eggs and any services related to procuring or storing donor gametes are excluded from the artificial insemination (in vivo) benefit. The artificial insemination benefit covers placement of sperm into the cervix or uterus and simple sperm preparation (e.g., sperm washing and isolation) but does not include donor gametes or their procurement/storage.

    The policy expands routine foot care services to include treatment of corns and calluses, trimming of nails, and foot care appliances for preventive care when medically necessary. This replaces the prior restriction that limited routine foot care only to people with a diagnosis of diabetes; the diabetes-only limitation has been removed.

    Services to procure or store donor sperm or donor eggs are not covered under the artificial insemination (in vivo) benefit. The covered artificial insemination benefit is limited to placement of sperm into the cervix or uterus and simple sperm preparation (such as washing and isolation) and excludes donor gametes and procurement or storage services.

    Coding, Limits, and Visit Frequency

    No explicit codes provided in this sectionmixed
    No codes listed
    Rehabilitative therapy visit cap — key values
    Rehabilitative therapy visit cap25 visits per Member per calendar year (combined outpatient rehabilitative speech, occupational, and physical therapy)
    Applies to modalitiesIncludes outpatient rehabilitative speech, occupational, and physical therapy and neurodevelopmental therapy when treating the same condition
    Authorization notePrior authorization may be required where plan rules implement visit limits; document services per plan procedures
    Hearing aid replacement frequency — key values
    Replacement frequencyOne hearing aid per ear every three years
    Associated serviceIncludes an annual hearing exam

    Provider Requirements, Prior Authorization, and Documentation

    Prior Authorization

    Obtain prior authorization for visit limits and hearing aid replacement

    Prior authorization may be required when plan rules enforce visit limits or device replacement frequency. Obtain authorization per plan procedures before scheduling services that count toward the combined outpatient rehabilitative therapy cap (25 visits per member per calendar year) or before replacing hearing aids more frequently than the plan’s replacement interval.

    • Prior authorization when combined outpatient rehabilitative therapy visits approach or exceed 25 per member per calendar year.
    • Prior authorization to confirm eligibility or coverage timing for hearing aid replacement (one hearing aid per ear every three years).
    Prior Authorization

    Check prior‑authorization rules for infertility evaluation and rehabilitative services

    Confirm whether a preliminary infertility evaluation and diagnosis is required by the plan before providing artificial insemination services; rehabilitation services that contribute to the combined outpatient visit cap may also need authorization.

    Definitions and Term Clarifications

    Essential Health Benefits — definition / key values
    DefinitionEssential Health Benefits (EHB) are the minimum benefit categories non-grandfathered individual and small group plans must cover under the ACA; includes ambulatory services, hospitalization, maternity/newborn care, mental health, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services, pediatric services (oral/vision), and others.
    Statutory referencesDefined by the ACA and RCW 48.43.005; SSB 5338 directed the OIC to review and update Washington's EHB benchmark plan
    ApplicabilityApplies to non-grandfathered individual and small group plans in Washington state when the benchmark plan is modified
    Artificial insemination (in vivo) — definition
    DefinitionArtificial insemination (in vivo) covers placement of sperm into the cervix or uterus to achieve pregnancy and includes simple sperm preparation such as sperm washing and isolation.

    Background and Scope

    Essential Health Benefits (EHBs) establish minimum coverage categories required by the Affordable Care Act for non-grandfathered individual and small group plans. Washington’s updated EHB benchmark adds and modifies benefits (for example, hearing aids, donor human milk, artificial insemination in vivo, and rehabilitative services) to align with state law and nondiscrimination requirements and applies to non-grandfathered individual and small group plans in Washington.

    Revision History and Actuarial Impacts

    2024-12-10actuarial_impactLatest

    Wakely EHB actuarial report projected allowed cost impacts for recommended benefits: Hearing Aids 0.07%, Human Donor Milk 0.02%, Artificial Insemination (in vivo) 0.01%.

    2026-01-01policy_effective_date

    Updated EHB benefits (including hearing aids, donor human milk, and artificial insemination) apply to plan years beginning January 1, 2026.

    Policy Summary
    PayerWashington Office of the Insurance Commissioner
    PolicyEssential Health Benefits expansion — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeMultiple additions and revisions to EHB benefits for PY2026
    Effective DateDec 10, 2024
    Next Review DateN/A
    Key ActionObtain and document a preliminary infertility evaluation and diagnosis when required to support coverage for artificial insemination benefits.
    SourceLink
    On This Page
    Coverage Criteria and Medical NecessityCoding, Limits, and Visit FrequencyProvider Requirements, Prior Authorization, and DocumentationDefinitions and Term ClarificationsBackground and ScopeRevision History and Actuarial Impacts
    Acupuncture: Yearly visit limitation for acupuncture care is removed.
    Pediatric dental crowns: Removes age limit for permanent indirect crowns; covers an indirect crown in a five-year period, per tooth, for permanent anterior teeth that are fully erupted.one crown per tooth per five-year period for erupted permanent anterior teeth

    Applies to pediatric major dental services - crowns and crown build-ups.

    Dollar limitNo dollar limit; large group policies with hearing aid benefit may not have a dollar limit as of 1/1/2026
    Outpatient rehabilitative therapy visit limit — key values
    Outpatient rehabilitative therapy limit25 visits per Member per calendar year (combined for outpatient speech, occupational, and physical therapy)
    IncludesNeurodevelopmental therapy and rehabilitation services to treat the same condition are covered under the limit
    Plan actionPrior authorization may apply when visit limits are enforced; follow plan-specific authorization procedures
  1. Document and, if required, obtain authorization for a covered preliminary infertility evaluation and diagnosis prior to artificial insemination in vivo.
  2. Check authorization requirements for neurodevelopmental or rehabilitative services that count toward the 25-visit combined limit.
    3. Documentation Required

    Document clinical findings and timing for covered benefits

    Providers should document clinical findings and plan-ordered services consistent with coverage criteria for each benefit before delivery of care.

    • For hearing aids: record annual hearing exam findings and timing of prior hearing aid per ear.
    • For artificial insemination: document indication and any preliminary infertility evaluation when performed.
    • For donor human milk and rehabilitative services: document medical necessity and applicable statutory criteria.
    Note

    Verify eligibility and remaining benefit limits before treatment

    Confirm member eligibility and plan-specific limits before initiating services that may be subject to combined visit caps or benefit-specific limits.

    • Verify member coverage for neurodevelopmental/rehabilitation therapies and remaining visits under the 25-visit combined cap.
    • Verify hearing aid benefit applicability and replacement timing (one hearing aid per ear every three years).
    Documentation Required

    Document RCW 48.43.815 criterion for donor human milk

    When billing for inpatient donor human milk, include documentation that the infant meets at least one criterion in RCW 48.43.815 to support medical necessity.

    • Attach clinical notes indicating why the infant is medically or physically unable to receive maternal human milk and cite which RCW 48.43.815 criterion is met.
    Documentation Required

    Document preliminary infertility evaluation and medical necessity when required

    When required by the plan, document a preliminary infertility evaluation and diagnosis before billing for artificial insemination; also document medical necessity when billing expanded routine foot care.

    • Record findings of the preliminary infertility evaluation and formal diagnosis in the medical record prior to artificial insemination services when the plan requires it.
    • For routine foot care billed as preventive/medical, document medical necessity (e.g., corns, calluses, nail trimming, foot appliances).
    Denial Risk

    Missing infertility evaluation or excluded donor‑gamete services can trigger denials

    Coverage for artificial insemination may be denied if the preliminary infertility evaluation and diagnosis are not documented; services related to procuring or storing donor gametes are excluded and may be denied as not covered.

    • Lack of documented preliminary infertility evaluation and diagnosis can preclude coverage for artificial insemination in vivo.
    • Services for donor sperm or eggs, or for procuring/storing donor gametes, are excluded from the artificial insemination benefit and can be denied.
    Denial Risk

    Risk of denial if preliminary infertility evaluation is not performed or documented

    Failure to perform or to document a preliminary infertility evaluation and diagnosis when the plan requires it may result in denial of artificial insemination benefit coverage.

    • Ensure the preliminary infertility evaluation and resulting diagnosis are present in the record before billing or seeking authorization for artificial insemination in vivo.
    ExclusionsDoes not include donor sperm or eggs, or services related to procuring or storing these materials
    Coverage notePreliminary infertility evaluation and diagnosis may be required prior to coverage for artificial insemination benefits
    Preliminary infertility evaluation — definition / clarification
    DefinitionPreliminary infertility evaluation and diagnosis are covered and may be required prior to receiving artificial insemination benefit coverage.
    DocumentationProviders should document the infertility evaluation and diagnosis when required by the plan to support coverage decisions
    Denial riskLack of documented preliminary infertility evaluation and diagnosis may preclude coverage for artificial insemination services
    Routine foot care (expanded) — definition
    Expanded routine foot care servicesIncludes treatment of corns and calluses, trimming of nails, and provision of foot care appliances for preventive care when medically necessary.
    Previous limitation removedCoverage previously limited to people with a diagnosis of diabetes; expansion removes that restriction when medical necessity is documented
    Documentation requirementMedical necessity must be documented when billing preventive foot care services under this expansion