well. Medical/surgical benefits and mental health or substance use WAC disorder benefits cannot be categorized as being offered outside of 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. Mental Health Mental Parity analysis must be done for each classification and applies to all WAC and Substance Health Parity treatment limitations (frequency of treatment, number of visits, days (Cont’d) of coverage, days in a waiting period, or other similar limits on the Use Disorder (“MH / SUD”) scope or duration of treatment). Look at: Services, Quantitative treatment limitations: expressed numerically (such as WAC Including fifty outpatient visits per year) Behavioral Includes annual, episode, and lifetime day and visit limits. Health Nonquantitative treatment limitations (“NQTL”): processes, WAC Treatment strategies, or evidentiary standards, or factors that are not (EHB) expressed numerically, but otherwise limit the scope or duration (Cont’d) of benefits for treatment. Includes, but not limited to: Limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; Formulary design; Methods for determining customary, and reasonable charges; Use of fail-first policies or step therapy protocols; Restrictions based on geographic location, facility type, provider specialty, and other
well. WAC Medical/surgical benefits and mental health or substance use disorder benefits cannot be categorized as being offered outside of 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. Mental Health and Substance Use Disorder (“MH / SUD”) Mental Health Parity (Cont’d) 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: Services, Including Behavioral WAC Quantitative treatment limitations: expressed numerically (such as fifty outpatient visits per year) Includes annual, episode, and lifetime day and visit limits. Health Treatment (EHB) (Cont’d) WAC Nonquantitative treatment limitations (“NQTL”): processes, strategies, or evidentiary standards, or 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 medical appropriateness, or based on whether the treatment is experimental or investigative; Formulary design; Methods for determining customary, and reasonable charges; Use of fail-first policies or step therapy protocols; Restrictions based on geographic location, facility type, provider specialty, and other
cl-forms-19-hmo-sg-analyst-checklist.docx