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Title: Section 98-4.3 - Definitions

Effective Date


98-4.3 Definitions.  For the purposes of this Subpart, the following definitions shall apply:

(a) Benefit classification means the following classifications of medical and surgical benefits and mental health and substance use disorder benefits for purposes of complying with the MHPAEA: inpatient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, emergency care and prescription drugs. The outpatient classification includes any subclassification of office visits.

(b) Comparative analysis means an analysis of the nonquantitative treatment limitations imposed on mental health or substance use disorder benefits to determine if such limitations are comparable to and applied no more stringently, both as written and in operation, than nonquantitative treatment limitations imposed on medical or surgical benefits within the same benefit classification. Comparative analysis includes the documented identification and assessment of the factors, processes, strategies, and evidentiary standards the MCO relied upon to determine the applicability and design of a nonquantitative treatment limitation and the processes and strategies the MCO used in operationalizing a nonquantitative treatment limitation to illustrate MCO compliance with MHPAEA.

(c) Compliance program means a mental health and substance use disorder parity compliance program.

(d) Financial requirements means deductibles, copayments, coinsurance, and out-of-pocket maximums.

(e) Latency period means the period of time that must elapse between the time at which a dose of drug is applied to a biologic system and the time at which a specified pharmacologic effect is produced.

(f) MHPAEA means the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, codified at 29 U.S.C. section 1185a, and its implementing regulations and sub-regulatory guidance.

(g) Nonquantitative treatment limitation means a qualitative limit affecting the scope or duration of benefits such as medical management standards limiting or excluding benefits based on medical necessity, or based on whether the treatment is experimental or investigational; formulary design for prescription drugs; network tier design; standards for provider admission to participate in a network, including reimbursement rates; methods for determining usual, customary, and reasonable charges; fail-first or step therapy protocols; exclusions based on failure to complete a course of treatment; and restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits.

(h) Provider means a physician, health care professional, or facility licensed, registered, certified, or otherwise authorized or accredited as required by state law.

(i) Quantitative treatment limitation means a numerical limit affecting the scope or duration of benefits.

Statutory Authority

Public Health Law, Section 4403


VOLUME A-2 (Title 10)