Health plans - Arizona

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. Arizona laws include the following provisions:

• If the plan covers dependent children of participants or beneficiaries it must cover dependent children who are placed with the participants or beneficiaries for adoption under the same terms and conditions that apply to the natural dependent children of the participants and beneficiaries, regardless of whether the adoption has become final. §20.1692.01
• The plan must not deny enrollment of a child because the child was born out of wedlock, is not claimed as a dependent on the parent's federal or state tax return, or does not reside with the parent or in the plan's service area. §20.1692.03
• Plans must not discriminate on the basis of hemophilia, genetic conditions, or victims of domestic violence. §20.448
• The plan must cover chiropractic services provided by network chiropractic providers. §20.1057.03
• The plan must allow any new enrollee whose health care provider is not a member of the provider network, on written request of the enrollee to the health care services organization, to continue an active course of treatment with that health care provider during a transitional period after the effective date of the enrollment. This applies if the enrollee has either a life threatening disease or condition, in which case the transitional period is not more than thirty days after the effective date of the enrollment; or has entered the third trimester of pregnancy on the effective date of the enrollment, in which case the transitional period includes the delivery and any care up to six weeks after the delivery that is related to the delivery. §20.1057.04
• If the plan covers medical supplies, it must cover for those medical supplies through one or more participating vendors who are reasonably accessible to enrollees. §30.1057.05
• The plan must not request information from a health care professional that does not apply to the medical condition at issue for the purposes of determining whether to approve or deny a prior authorization request. §20.1057.06
• The plan is not obligated to pay any costs, other than covered patient costs, that are directly associated with a cancer clinical trial in which the enrollee participates voluntarily. §20.1507.07
• If the plan covers prescriptions, it must cover FDA-approved contraceptives, if prescribed. §20.1507.08
• The plan must cover an initial medical screening examination and any immediately necessary stabilizing without prior authorization by the plan. §20.2803

State

Contact

Arizona Department of Insurance

Regulations

The laws governing which practitioners employees may see may follow the same rules that apply to disability coverage (see Arizona Employee Benefits). Some of the laws that directly impact health insurance are as follows:

§20-1692.03 – Coverage of children

§20-448 – Unfair discrimination, definitions

§20-1057 – Evidence of coverage by health care services organizations; renewability; definitions

§20-1057.01 – Referrals

§20-1057.02 – Prescription drug formulary

§20-1057.03 – Chiropractic care

§20-1057.04 – Continuity of care

§20-1057.05 – Medical supplies

§20-1057.06 – Prior authorization

§20-1057.07 – Health care services organizations; clinical trials; cancer; definitions

§20-1057.08 – Prescription contraceptive drugs and devices

§20-2803 – Emergency services access; prior authorizations; requirements

Arizona insurance codes may be found in the Arizona Revised Statutes, Chapter 20

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)