New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-4 › Section 98-4.3 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
For the purposes of this Subpart, the following
						definitions shall apply:
(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. 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, both as written
					 and in operation, than 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 MCO relied upon to
					 determine the applicability and design of a nonquantitative treatment
					 limitation and the processes and strategies the MCO used in operationalizing a
					 nonquantitative treatment limitation to illustrate MCO 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)
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.
(f)
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.
(g)
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.
(h) Provider
					 means a physician, health care professional, or facility licensed, registered,
					 certified, or otherwise authorized or accredited as required by state
					 law.
(i)
Quantitative
					 treatment limitation
means a numerical limit affecting the scope or
					 duration of benefits.