Use Disorder (Cont’d) these six classifications and therefore not subject to the parity Services, analysis. A health plan or issuer must treat the least restrictive level Including of the financial requirement or quantitative treatment limitation that applies to at least two-thirds of medical/surgical benefits across all Behavioral Health provider tiers in a classification as the predominant level that it may Treatment apply to mental health or substance use disorder benefits in the same classification. (EHB) Parity analysis must be done for each classification and applies to all WAC (Cont’d) treatment limitations (frequency of treatment, number of visits, days of coverage, days in a waiting period, or other similar limits on the WAC scope or 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 limits. Nonquantitative treatment limitations (“NQTL”): processes, WAC 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: Mental Health Mental Limiting or excluding benefits based on medical necessity or WAC and Substance Health Parity medical appropriateness, or based on whether the treatment (a) (Cont’d) is experimental or investigative; Use Disorder Formulary design; (b) For plans with multiple network tiers (such as preferred providers Services, (c) and participating providers), network tier design; Including Standards for provider admission to participate in a network, Behavioral (d) including reimbursement rates; Health Treatment Methods for determining usual, customary, and reasonable (e) (EHB) charges;
Use Disorder Services, Including Behavioral Health Treatment (Cont’d) these six classifications and therefore not subject to the parity analysis. A health plan or issuer must treat the least restrictive level of the financial requirement or quantitative treatment limitation that applies to at least 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. (EHB) (Cont’d) WAC WAC 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 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: Mental Health and Substance Use Mental Health Parity (Cont’d) WAC (a) Limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; Disorder (b) Formulary design; Services, Including (c) For plans with multiple network tiers (such as preferred providers and participating providers), network tier design; Behavioral Health (d) Standards for provider admission to participate in a network, including reimbursement rates; Treatment (EHB) (e) Methods for determining usual, customary, and reasonable charges;
checklist-forms-2018-disability-sg-analyst-checklist.docx