Ariz. Admin. Code § 20-6-1302

Current through Register Vol. 30, No. 45, November 8, 2024

Section R20-6-1302 - Medical Necessity Criteria and NQTL Reporting

A. Health care insurers subject to the reporting requirement. A health care insurer that issues health plans in Arizona is required to file the reports required by this Section with the Department.

B. Health plans subject to reporting. A health care insurer shall submit a report for all health plans it offers in this state (including grandfathered and non-grandfathered health plans) that meet all of the criteria listed in subsections (B)(1) through (B)(4) of this Section. If a health care insurer determines that the information to be reported varies by network plan, or varies in the individual, small group, or large group market, the health care insurer must submit a separate report for each variation.

1. The health plan offers MH and/or SUD benefits in addition to Med/Surg benefits.

2. The health plan offers MH and/or SUD benefits in at least one of the following classifications:

a. Inpatient, in-network;

b. Inpatient, out-of-network;

c. Outpatient, in-network;

d. Outpatient, out-of-network;

e. Emergency care; or

f. Prescription drugs.

3. The health plan is offered on a group (large or small) or individual basis.

4. The health plan has not received and notified the Department of an increased cost exemption pursuant to 45 CFR 146.136(g).

C. Health plans exempt from reporting. A health plan that meets the criteria of subsection (B) of this Section is exempt from reporting under this Article if it is one of the following types of health plans:

1. A small group grandfathered health plan;

2. A small group non-grandfathered health plan subject to the HHS transitional policy; or

3. A health plan that meets the definition of excepted benefit provided in 45 CFR 146.145(b) or 45 C.F.R. 148.220.

D. Required reports. A health care insurer shall file a separate report for each fully insured product network type the health care insurer issues in Arizona. If the information to be reported varies by network or health plan, or varies in the individual, small group or large group market, the health care insurer must file a separate report for each variation.

E. Triennial Reports.

1. Existing health care insurers. Beginning on March 15, 2023 and every third year thereafter, a health care insurer issuing health plans and collecting premium in Arizona as of January 1, 2022 shall file a triennial report with the Department for each health plan subject to reporting.

2. Entering or re-entering health care insurers. On or before March 15 of the second year an entering or re-entering health care insurer issues health plans and collects premiums in Arizona, the health care insurer shall file an original triennial report with the Department for each health plan subject to reporting. Following the filing of the original triennial report, the health care insurer shall submit subsequent triennial reports on the schedule described in subsection (E)(1) of this Section.

3. Due date for triennial reports. Triennial reports are due on or before March 15 of each reporting year.

4. Content of the original triennial report. Health care insurers shall file an original triennial report with the Department under A.R.S. § 20-3502(B) that provides the required information in Exhibit A.

5. Subsequent triennial reports.

a. A health care insurer must file an updated triennial report, including the information required in Exhibit A, unless the health care insurer can attest that it has made no changes since the previously filed triennial report.

b. As required by A.R.S. § 20-3502(E), a health care insurer shall file the following with the Department for each health plan subject to reporting:

i. An updated triennial report, including the information required in Exhibit A; or

ii. The last triennial report filed with the Department and a written attestation that the health care insurer has made no changes since it filed the previous triennial report.

F. Annual Reports. Pursuant to A.R.S. § 20-3502(E), on or before March 15 of each intervening year between the filing of a triennial report, a health care insurer shall file:

1. A report that summarizes any changes made to its medical necessity criteria and NQTLs (Exhibit A, Parts I, II, and III);

2. A written attestation by an officer or director of the health care insurer that the health care insurer is in compliance with MHPAEA; and

3. If requested by the Department, any additional data required by the Department including Exhibit A, Part IV.

G. Additional information. At any time after a health care insurer files a report under this Section, the Department may request additional information, including an updated triennial or annual report, by contacting the health care insurer and making the request in writing. The health care insurer shall provide contact information to the Department when it files any of the reports required by this Section. The Department may set a deadline for a health care insurer to respond to its request and specify the format for the response.

Ariz. Admin. Code § R20-6-1302

New Section made by final rulemaking at 28 A.A.R. 1824, effective 9/4/2022.