Ariz. Admin. Code § 20-6-1301
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.
Ariz. Admin. Code § R20-6-1301