For Consumers

Benefits health plans must cover under Washington state law

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. 

Essential health benefits in Washington state by health plan type

Health benefit

Description

Plan type*

Abortion coverage limitations (effective 1/1/2019)

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
Group

Anesthesia for dental services

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

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

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

Group

Colorectal cancer exams and lab tests

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

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

Individual/family
Group

Contraceptive coverage


Contraceptive coverage

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
Group

Diabetes coverage

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

Individual/family
Group

Donor human milk

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:

  • An infant who is medically or physically cannot receive maternal human milk or participate in chest feeding

  • A parent who is medically or physically unable to produce maternal human milk in sufficient quantities or caloric density or participate in chest feeding.

Group (Effective Jan. 1, 2023)

Emergency medical services in an emergency department

Emergency services must be covered by health plans if a medical provider believes a patient is having an emergency. 

Individual/family
Group

Gender affirming care

Health insurers generally cannot exclude, deny or limit medically-necessary gender-affirming treatment.

Individual/family
Group

Injury caused by intoxication or narcotics

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

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

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

Individual

Mental health parity

Health plans must cover mental health services the same way they cover medical and surgical services.

Individual/family
Group

Neurodevelopmental therapies

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

Group

Phenylketonuria (PKU)

Health plans must cover the formulas necessary to treat PKU.

Individual/family
Group

Prostate cancer screening

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)

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

Voluntary sterilization (effective 1/1/2019)

Health plans must provide coverage for voluntary sterilization without requiring copayments, deductibles or cost sharing.

Individual/family
Group

Women’s health care services

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.

*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.