Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 06 - DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS - INSURANCE DIVISION › Article 13 - MENTAL HEALTH PARITY › Section R20-6-1301 - Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
The definitions in A.R.S. §
									20-3501
				  and the following definitions apply to this Article:
"Arizona Mental Health Parity Act" means the statutes found
				  at A.R.S. §§
									20-3501
				  through
				  20-3505.
"Coverage unit" has the meaning prescribed at
				  45 CFR
				  §
										146.136(a) "Coverage
				  unit."
"Department of Insurance and Financial Institutions
				  (Department)" has the meaning prescribed at A.R.S. §
									20-101.
"CMS MHPAEA tool" means the Microsoft Excel Mental Health
				  Parity tool maintained by the Center for Medicare and Medicaid Services.
"Financial requirements (FR)" has the meaning at
				  45 CFR
				  §
										146.136(a) "Financial
				  requirements."
"Health care insurer" has the meaning prescribed at A.R.S.
				  §
									20-3501(2).
"Health plan" has the meaning prescribed at A.R.S. §
									20-3501(3).
"Inpatient, in-network benefits" are benefits furnished on
				  an inpatient basis and within a network of contracted providers under a health
				  plan.
"Inpatient, out-of-network benefits" are benefits furnished
				  on an inpatient basis by providers without a contract under a health plan or
				  for a health plan that has no network of providers.
"Large group health plan" is a health plan issued to an
				  employer group that is not a small employer as defined at A.R.S. §
									20-2301(A)(20).
"Medical/surgical (Med/Surg) benefits" has the meaning
				  prescribed at
				  45 CFR
				  §
										146.136(a)
				  "Medical/surgical benefits."
"Mental (MH) health benefits" has the meaning prescribed at
				  45 CFR
				  §
										146.136(a) "Mental
				  health benefits."
"MHPAEA" means the Mental Health Parity and Addiction Equity
				  Act prescribed in A.R.S. §
									20-3501(4).
"Nonquantitative treatment limitation (NQTL)" is a
				  limitation that restricts the scope or duration of benefits for treatment under
				  a health plan or coverage. Illustrations of NQTLs include: medical management
				  standards limiting or excluding benefits based on medical necessity or
				  appropriateness or based on whether the treatment is experimental or
				  investigative as identified under
				  45 CFR
				  146.136(c)(4)(ii)(A);
				  formulary design for prescription drugs as identified under
				  45 CFR
				  146.136(c)(4)(ii)(B);
				  network tier design (for health plans with multiple network tiers such as
				  preferred providers and participating providers) as identified under
				  45 CFR
				  146.136(c)(4)(ii)(C);
				  standards for provider admission to participate in a network, including
				  reimbursement rates as identified under
				  45 CFR
				  146.136(c)(4)(ii)(D);
				  methods for determining usual, customary, and reasonable charges as identified
				  under
				  45 CFR
				  146.136(c)(4)(ii)(E);
				  refusal to pay for higher-cost therapies until it can be shown that a
				  lower-cost therapy is not effective (also known as "fail-first policies" or
				  "step therapy protocols") as identified under
				  45 CFR
				  146.136(c)(4)(ii)(F);
				  exclusions based on failure to complete a course of treatment; and restrictions
				  based on geographic location as identified under
				  45 CFR
				  146.136(c)(4)(ii)(G),
				  facility type, provider specialty, and other criteria than limit the scope or
				  duration of benefits for services provided under the health plan or coverage as
				  identified under
				  45 CFR
				  146.136(c)(4)(ii)(H).
"Outpatient, in-network benefits" are benefits furnished on
				  an outpatient basis and within a network of providers established or recognized
				  under a health plan.
"Outpatient, out-of-network benefits" are benefits furnished
				  on an outpatient basis and outside any network of providers established or
				  recognized under a health plan or under a health plan that has no network of
				  providers.
"Predominant test" means that if a type of FR or QTL applies
				  to substantially all of the Med/Surg benefits in a classification, the
				  predominant level of the FR or QTL is the level that applies to more than 1/2
				  of the Med/Surg benefits in that classification subject to the FR or QTL. If no
				  single level can be determined, the health plan (or health insurance issuer)
				  may combine levels until the combination of levels applies to more than 1/2 of
				  Med/Surg benefits subject to the FR or QTL in the classification. The least
				  restrictive level within the combination is considered the predominant level of
				  that type of classification. For this purpose, a health plan may combine the
				  most restrictive levels first with each less restrictive level added to the
				  combination until the combination applies to more than 1/ 2 of the benefits
				  subject to the FR or QTL.
"Quantitative treatment limitation (QTL)" is a limitation on
				  the scope or duration of a benefit that can be expressed numerically that
				  includes day or visit limits such as "50 outpatient visits per year." QTLs
				  include annual, episode, and lifetime day and visit limits such as number of
				  treatments, number of visits, or days of coverage.
"Substance use disorder (SUD) benefits has the meaning
				  prescribed at
				  45 CFR
				  §
										146.136(a) "Substance
				  use disorder benefits."
"Substantially all test" means that a FR or QTL applies to
				  at least 2/3 of all Med/Surg benefits in a classification of benefits for a
				  coverage unit. (For this purpose, benefits expressed as subject to a zero level
				  of a type of FR are treated as not subject to that type of FR. In addition,
				  benefits expressed as subject to an unlimited QTL are treated as not subject to
				  that type of QTL.) If a type of FR or QTL does not apply to at least 2/3 of all
				  Med/Surg benefits in a classification, then that type of FR or QTL cannot be
				  applied to MH or SUD benefits in that classification.