New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter IX - Unfair Trade Practices › Part 230 - Mental Health and Substance Use Disorder Parity Compliance Program › Section 230.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Part:
(a)
Benefit classification
means the following classifications of medical and surgical benefits and mental
				health and substance use disorder benefits for purposes of complying with the
				MHPAEA: inpatient in-network, inpatient out-of-network, outpatient in-network,
				outpatient out-of-network, emergency care and prescription drugs. Provided,
				however, the outpatient classification includes any subclassification of office
				visits.
(b)
Comparative
				analysis means
an analysis of the nonquantitative treatment
				limitations imposed on mental health or substance use disorder benefits to
				determine if such limitations are comparable to and applied no more stringently
				than, both as written and in operation, nonquantitative treatment limitations
				imposed on medical or surgical benefits within the same benefit classification.
				Comparative analysis includes the documented identification and assessment of
				the factors, processes, strategies, and evidentiary standards the insurer
				relied upon to determine the applicability and design of a nonquantitative
				treatment limitation and the processes and strategies the insurer used in
				operationalizing a nonquantitative treatment limitation to illustrate insurer
				compliance with MHPAEA.
(c)
Compliance program
means a mental health and substance use
				disorder parity compliance program.
(d)
Financial requirements
means deductibles, copayments, coinsurance, and out-of-pocket
				maximums.
(e)
Insurer
means an insurer authorized to write accident and
				health insurance in this State, a corporation organized pursuant to Insurance
				Law Article 43, student health plans certified pursuant to Insurance Law
				section 1124, and municipal cooperative health benefit plans certified pursuant
				to Insurance Law Article 47 and a health maintenance organization certified
				pursuant to Public Health Law Article 44.
(f)
Latency period
means the
				period of time that must elapse between the time at which a dose of drug is
				applied to a biologic system and the time at which a specified pharmacologic
				effect is produced.
(g) MHPAEA
				means the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
				Equity Act of 2008, codified at
				29
				U.S.C. section 1185a, and its implementing
				regulations and sub-regulatory guidance.
(h)
Nonquantitative treatment
				limitation
means a qualitative limit affecting the scope or duration
				of benefits such as medical management standards limiting or excluding benefits
				based on medical necessity, or based on whether the treatment is experimental
				or investigational; formulary design for prescription drugs; network tier
				design; standards for provider admission to participate in a network, including
				reimbursement rates; methods for determining usual, customary, and reasonable
				charges; fail-first or step therapy protocols; exclusions based on failure to
				complete a course of treatment; and restrictions based on geographic location,
				facility type, provider specialty, and other criteria that limit the scope or
				duration of benefits.
(i) Provider
				means a physician, health care professional, or facility licensed, registered,
				certified, or otherwise authorized or accredited as required by state
				law.
(j) Quantitative treatment
				limitation means a numerical limit affecting the scope or duration of
				benefits.