two-thirds of medical/surgical benefits across all provider tiers in a classification as the predominant level that it may apply to mental health or substance use disorder benefits in the same classification. Mental Parity analysis must be done for each classification and applies to all WAC Health treatment limitations (frequency of treatment, number of visits, days of WAC Parity coverage, days in a waiting period, or other similar limits on the scope or 284-43-7010 (Cont’d) duration of treatment). Look at: Quantitative treatment limitations: expressed numerically (such as WAC fifty outpatient visits per year) Includes annual, episode, and lifetime day and visit limits. Nonquantitative treatment limitations (“NQTL”): processes, strategies, WAC or evidentiary standards, or other factors that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. Includes, but not limited to: Limiting or excluding benefits based on medical necessity or WAC medical appropriateness, or based on whether the treatment is (a) experimental or investigative; Formulary design; (b) For plans with multiple network tiers (such as preferred providers and (c) participating providers), network tier design; Standards for provider admission to participate in a network, including (d) reimbursement rates; Methods for determining customary, and reasonable (e) charges; Use of fail-first policies or step therapy protocols; (f) Exclusions on failure to complete a course of treatment; and (g)
Mental Health Parity (Cont’d) two-thirds of medical/surgical benefits across all provider tiers in a classification as the predominant level that it may apply to mental health or substance use disorder benefits in the same classification. WAC WAC 284-43-7010 Parity analysis must be done for each classification and applies to all treatment limitations (frequency of treatment, number of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration of treatment). Look at: WAC Quantitative treatment limitations: expressed numerically (such as fifty outpatient visits per year) Includes annual, episode, and lifetime day and visit limits. WAC Nonquantitative treatment limitations (“NQTL”): processes, strategies, or evidentiary standards, or other factors that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. Includes, but not limited to: WAC (a) Limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (b) Formulary design; (c) For plans with multiple network tiers (such as preferred providers and participating providers), network tier design; (d) Standards for provider admission to participate in a network, including reimbursement rates; (e) Methods for determining customary, and reasonable charges; (f) Use of fail-first policies or step therapy protocols; (g) Exclusions on failure to complete a course of treatment; and
cl-forms-19-hmo-ind-analyst-checklist.docx