For Consumers

Benefits health plans must cover under Washington state law

In addition to the essential health benefits covered under the Affordable Care Act, certain individual/family and group health plans must also offer the following benefits per Washington state law.

Note: While health plans are required to include these benefits, your medical services, supplies and prescription drugs are still subject to the plan’s medical necessity criteria. Contact your health plan for more information.

Health benefitDescriptionPlan type*

Anesthesia for dental services (leg.wa.gov)

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

Cancer chemotherapy medications (leg.wa.gov)

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 
Group (effective Jan. 1, 2012)

Chemical dependency (leg.wa.gov)

Treatment of chemical dependency must be covered in an approved treatment facility program.

Group

Colorectal cancer exams and lab tests (leg.wa.gov)

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
Group

Congenital anomalies in children and newborns (leg.wa.gov)

Newborn infants must be covered from birth. The coverage must include treatment of congenital anomalies.

Individual/family
Group

Contraceptive coverage (leg.wa.gov)

Health plans providing generally comprehensive coverage of prescription drugs and/or prescription devices must cover contraceptives on the same basis as other prescription drugs and devices.

Individual/family
Group

Diabetes coverage (leg.wa.gov)

Health plans must cover medically necessary diabetes equipment, supplies, education and training.

Individual/family
Group

Emergency medical services in an emergency department (leg.wa.gov)

Health plans must cover emergency services provided in an emergency department if a medical provider believes patient is having an emergency.

Individual/family
Group

Injury caused by intoxication or narcotics (leg.wa.gov)

Health plans cannot deny coverage of an injury only because it was sustained while intoxicated or under the influence of a narcotic.

Individual/family
Group

Mammograms (leg.wa.gov)

Health plans must cover screening or diagnostic mammography services if recommended by a physician or advanced registered nurse practitioner.

Individual/family
Group

Maternity and drug coverage (leg.wa.gov)

All individual health plans must include coverage for maternity services and prescription drug coverage.

Individual

Mental health parity (leg.wa.gov)

All health plans must include the same coverage for mental health services that they provide for other medical and surgical services.

Individual/family
Group

Neurodevelopmental therapies (leg.wa.gov)

Health plans must cover neurodevelopmental therapies (occupational therapy, speech therapy, physical therapy) for enrollees age six or younger.

Group

Phenylketonuria (PKU) (leg.wa.gov)

Health plans must cover the formulas necessary to treat PKU.

Individual/family
Group

Prostate cancer screening (leg.wa.gov)

Health plans must cover prostate cancer screenings recommend by the patient's physician, advanced registered nurse practitioner or physician assistant.

Individual/family
Group

Temporomandibular joint disorder (TMJ) (leg.wa.gov)

Offer employers optional coverage for TMJ, which can cause pain in the jaw joint and in the muscles that control jaw movement. (Employers are not required to include this benefit in the plan.)

Group

Women’s health care services (leg.wa.gov)

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
Group

*Individual/family health plan: A plan individuals and their dependents buy directly from an insurance agent or through the state's health benefit exchange (wahealthplanfinder.org).

*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.