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 R20-6-1303 - FR and QTL Reporting

Current through Register Vol. 30, No. 28, July 12, 2024
A. Method of
				reporting. A health care insurer that issues health plans in Arizona and whose
				policy forms are not exempt from the form filing requirement shall demonstrate
				its compliance with the FR and QTL parity requirements of MHPAEA through its
				form and rate filings with the Department.
B. Department's authority to require
				additional data. In addition to the forms filed by a health care insurer, the
				Department may require a health care insurer to submit additional data relating
				to its methods for meeting the MHPAEA FR and QTL standards. The Department may
				utilize the CMS MHPAEA tool and may request samples of a health care insurer's
				internal testing to demonstrate compliance with the substantially all and
				predominant tests within each classification of benefits for a health
				plan.
C. Separate consolidated
				report for large group health plans. The Department may require a health care
				insurer that issues large group health plans to file a consolidated report that
				demonstrates compliance with the substantially all and predominant tests within
				each classification of benefits for a sample of large group health plans with
				similar benefit structures.
D.
				Special rule for FRs - Prescription Drug Classification. The multi-tiered
				prescription drug benefits exception of A.R.S. §
									20-3502(D)(1)
				 applies to the FRs for the prescription drug
				classification. For example, a health plan applies 4 tiers as follows: Tier 1:
				Generic Drugs for which the health plan pays 90%; Tier 2: Preferred Brand-name
				Drugs for which the health plan pays 80%; Tier 3: Non-preferred Brand-name
				Drugs for which the health plan pays 60%; and Tier 4: Specialty Drugs for which
				the health plan pays 50%. These FRs are applied without regard to whether a
				drug is prescribed for Med/Surg or MH/SUD benefits. In addition, the process
				for certifying a particular drug within a tier complies with the rules for
				NQTLs. Therefore, the FRs applied to prescription drug benefits meet the parity
				requirements under MHPAEA.
E.
				Special rules for FRs and QTLs.
1. In-network
				Classifications. The multiple network tiers exception of A.R.S. §
										20-3502(D)(2)
				 applies to the FRs and QTLs for the
				in-network classifications. For example, a health plan has two tiers of
				in-network providers: Tier 1: Preferred provider; and Tier 2: Participating
				provider. Placement of a provider into a tier complies with the rules for NQTLs
				and is determined without regard to whether the provider specializes in the
				treatment of Med/Surg conditions or MH/SUD disorders. The in-network
				classifications are divided into two subclassifications:
1. In-network preferred; and
2. In-network participating. The health plan
				does not impose any FR or QTL on MH/SUD benefits in either subclassification
				that is more restrictive than the predominant FR or QTL that applies to all
				Med/Surg benefits in each subclassification. Therefore, the FRs or QTLs applied
				to the in-network subclassifications that reflect the provider tiers meet the
				parity requirements under MHPAEA.
2. Outpatient Classifications. The
				subclassification permitted for the office visits exception of A.R.S. §
										20-3502(D)(3)
				 applies to the FRs and QTLs for the
				outpatient classifications. For example, a health plan divides the outpatient,
				in-network classification into two subclassifications:
1. In-network office visits; and
2. All other outpatient, in-network items and
				services. The health plan does not impose any FR or QTL on MH/SUD benefits in
				either subclassification that is more restrictive than the predominant FR or
				QTL that applies to Med/Surg benefits in each subclassification. Therefore, the
				FRs or QTLs applied to the outpatient subclassifications for office visits and
				all other outpatient items and services meet the parity requirements under
				MHPAEA.
The health plan cannot use a subclassification for
				  generalists and specialists. The only subclassifications permitted for the
				  in-network classifications are:
1. Office visits (such as physician visits);
				and
2. All other outpatient items
				and services (such as outpatient surgery, facility charges for day treatment
				centers, laboratory charges, or other medical items).