Instructions for Exhibit A:
Submit an Exhibit A for each fully insured, major medical health plan subject to reporting under Section R20-6-1302(B). Please submit the information in a word-searchable PDF file which is organized and identified by the numbered sections that appear below.
Part I: Identify Plan and Reporting Year.
Instructions for Part I:
The reporting year is the year, from January 1 through December 31, immediately preceding the submission of this Exhibit A.
Reporting Year: | |
Health Care Insurer Name: | |
Health Care Insurer NAIC Company Code: | |
Network Name(s): | |
Service Area: (List all counties in the service area for these networks) | |
Covered Lives: (List the number of covered lives enrolled in plans in these networks in the reporting year) | |
Plan Types: (Check all that apply) | []Individual ACA-Compliant | []Small Group ACA-Compliant |
[]Individual Transitional, plans include | []Small Group Transitional, plans include |
MH/SUD benefits | MH/SUD benefits |
Individual Grandfathered, plans include | Large Group Fully Insured, plans include |
MH/SUD benefits | MH/SUD benefits |
Product Types: (Check all that apply) | []PPO | []HMO (HCSO) |
[]POS | []Indemnity |
Part II: Medical necessity criteria.
Instructions for Part II:
To comply with A.R.S. § 20-3502(B)(1), describe the process that is used to develop or select medical necessity criteria for the plan and reporting year identified in Part I. When the plan describes the process used to develop or select criteria for MH/SUD benefits, then it must also describe the process used to develop or select criteria for Med/Surg benefits.
To comply with A.R.S. § 20-3502(B)(1), report:
A. Describe the process used to develop or select medical necessity criteria for MH/SUD benefits.B. Describe the process used to develop or select medical necessity criteria for Med/Surg benefits. Part III: Identify all NQTLs.
Instructions for Part III:
To comply with A.R.S. § 20-3502(B)(2), identify all NQTLs that are applied to MH/SUD benefits and all NQTLs that are applied to Med/ Surg benefits for the plan and reporting year identified in Part I. NQTLs shall be identified within each classification of benefits.
A. Identify and report all NQTLs applied to MH/SUD benefits:1. All NQTLs applied to In-Patient, In-Network Classification.2. All NQTLs applied to In-Patient, Out-of-Network Classification3. All NQTLs applied to Out-Patient, In-Network Classification4. All NQTLs applied to Out-Patient, Out-of-Network Classification5. All NQTLs applied to Emergency Care6. All NQTLs applied to Prescription BenefitsB. Identify and report all NQTLs applied to Med/Surg benefits: 1. All NQTLs applied to In-Patient, In-Network Classification.2. All NQTLs applied to In-Patient, Out-of-Network Classification3. All NQTLs applied to Out-Patient, In-Network Classification4. All NQTLs applied to Out-Patient, Out-of-Network Classification5. All NQTLs applied to Emergency Care6. All NQTLs applied to Prescription Benefits Part IV: Demonstrate parity through analysis.
Instructions for Part IV:
To comply with A.R.S. § 20-3502(B)(3), for each NQTL listed in Part III, demonstrate through analysis that the process, strategy, evidentiary standard, and other factor of applying the NQTL to MH/SUD benefits in a classification of benefits, as written and in operation, is comparable to, and applied not more stringently than, any process, strategy, evidentiary standard or other factor used in applying the NQTL to Med/Surg benefits in the same classification. The report should define each "Other Factor" and include qualitative and quantitative statistical data to support and explain the analysis.
Identify and report on the NQTLs reported in Part III as follows:
A. Classification - Inpatient, in-network1. Process a. Process applying NQTL to MH/SUD benefit.b. Process applying NQTL to Med/Surg benefit.c. Analysis showing that the process of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the process of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.2. Strategy a. Strategy applying NQTL to MH/SUD benefit.b. Strategy applying NQTL to Med/Surg benefit.c. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.3. Evidentiary Standarda. Evidentiary standard applying NQTL to MH/SUD benefit.b. Evidentiary standard applying NQTL to Med/Surg benefit.c. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.4. Other Factor a. Other factor applying NQTL to MH/SUD benefit.b. Other factor applying NQTL to Med/Surg benefit.c. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, as written, are comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, in operation, are comparable to and not applied more stringently than to Med/Surg benefits.B. Classification - Inpatient, out-of-network1. Processa. Process applying NQTL to MH/SUD benefit.b. Process applying NQTL to Med/Surg benefit.c. Analysis showing that the process of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the process of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.2. Strategy a. Strategy applying NQTL to MH/SUD benefit.b. Strategy applying NQTL to Med/Surg benefit.c. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.3. Evidentiary Standarda. Evidentiary standard applying NQTL to MH/SUD benefit.b. Evidentiary standard applying NQTL to Med/Surg benefit.c. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.4. Other Factor a. Other factor applying NQTL to MH/SUD benefit.b. Other factor applying NQTL to Med/Surg benefit.c. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, as written, are comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, in operation, are comparable to and not applied more stringently than to Med/Surg benefits.C. Classification - Outpatient, in-network1. Processa. Process applying NQTL to MH/SUD benefit.b. Process applying NQTL to Med/Surg benefit.c. Analysis showing that the process of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the process of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.2. Strategy a. Strategy applying NQTL to MH/SUD benefit.b. Strategy applying NQTL to Med/Surg benefit.c. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.3. Evidentiary Standarda. Evidentiary standard applying NQTL to MH/SUD benefit.b. Evidentiary standard applying NQTL to Med/Surg benefit.c. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.4. Other Factor a. Other factor applying NQTL to MH/SUD benefit.b. Other factor applying NQTL to Med/Surg benefit.c. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, as written, are comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, in operation, are comparable to and not applied more stringently than to Med/Surg benefits.D. Classification - Outpatient, out-of-network1. Processa. Process applying NQTL to MH/SUD benefit.b. Process applying NQTL to Med/Surg benefit.c. Analysis showing that the process of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the process of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.2. Strategy a. Strategy applying NQTL to MH/SUD benefit.b. Strategy applying NQTL to Med/Surg benefit.c. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits. d. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.3. Evidentiary Standard a. Evidentiary standard applying NQTL to MH/SUD benefit.b. Evidentiary standard applying NQTL to Med/Surg benefit.c. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.4. Other Factor a. Other factor applying NQTL to MH/SUD benefit.b. Other factor applying NQTL to Med/Surg benefit.c. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, as written, are comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, in operation, are comparable to and not applied more stringently than to Med/Surg benefits.E. Classification - Emergency care1. Process a. Process applying NQTL to MH/SUD benefit.b. Process applying NQTL to Med/Surg benefit.c. Analysis showing that the process of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the process of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.2. Strategy a. Strategy applying NQTL to MH/SUD benefit.b. Strategy applying NQTL to Med/Surg benefit.c. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.3. Evidentiary Standarda. Evidentiary standard applying NQTL to MH/SUD benefit.b. Evidentiary standard applying NQTL to Med/Surg benefit.c. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.4. Other Factor a. Other factor applying NQTL to MH/SUD benefit.b. Other factor applying NQTL to Med/Surg benefit.c. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, as written, are comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, in operation, are comparable to and not applied more stringently than to Med/Surg benefits.F. Classification "" Prescription benefits1. Processa. Process applying NQTL to MH/SUD benefit.b. Process applying NQTL to Med/Surg benefit.c. Analysis showing that the process of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the process of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.2. Strategy a. Strategy applying NQTL to MH/SUD benefit.b. Strategy applying NQTL to Med/Surg benefit.c. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the strategy of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.3. Evidentiary Standarda. Evidentiary standard applying NQTL to MH/SUD benefit.b. Evidentiary standard applying NQTL to Med/Surg benefit.c. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, as written, is comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that the evidentiary standard of applying the NQTL to MH/SUD benefits, in operation, is comparable to and not applied more stringently than to Med/Surg benefits.4. Other Factor a. Other factor applying NQTL to MH/SUD benefit.b. Other factor applying NQTL to Med/Surg benefit.c. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, as written, are comparable to and not applied more stringently than to Med/Surg benefits.d. Analysis showing that other factors used to apply the NQTL to MH/SUD benefits, in operation, are comparable to and not applied more stringently than to Med/Surg benefits. Ariz. Admin. Code tit. 20, ch. 06, art. 13, exh. A
New Section made by final rulemaking at 28 A.A.R. 1825, effective 9/4/2022.