Plan design (HMOs, PPOs, POS plans, deductibles, coinsurance, copays, out-of-pocket maximums) is covered in the national Medical Plans guide. Arizona's Health exam adds a few state rules: the health care appeals process, prompt payment of provider claims, telehealth parity, and limits on dental fee schedules.

Health care appeals (A.R.S. 20-2533)

Arizona requires three levels of review for a denied service, with no minimum dollar amount:

1. an expedited medical review and appeal for urgent cases
2. an initial appeal
3. an external independent review

Prompt payment of provider claims (20-3102)

Unless the provider contract says otherwise:

• a health care insurer must adjudicate a clean claim within 30 days of receipt
• it must pay the approved portion within 30 days after adjudication
• late payments carry interest

Telehealth (20-1376.05)

A disability (health) insurer must cover a service delivered through telehealth if the same service would be covered in person.

Dental fee schedules (20-1342.06)

A disability insurer's contract with an Arizona dentist may require the dentist to accept the insurer's set fee only for covered services. It can't set fees for services the patient's policy doesn't cover.

Selling health plans

• The definition of solicit includes steering, advising, or encouraging people with a known health condition to drop their coverage and buy a replacement. Doing that as a regular business requires a producer license (20-281).
• A producer, consultant, or TPA may not falsely disclose the compensation tied to a health benefits plan (20-443(B)).
• Premiums paid for an enrollee by a health care provider, institution, or drug manufacturer are a prohibited rebate (20-449(A)).
• A health insurer may not unfairly discriminate between individuals of the same class and essentially the same hazard (20-448(B)).
• A health insurer may not use a genetic condition to reject or rate an application, absent a diagnosis related to genetic test information.

Common exam traps

• Arizona's appeal process has three levels: expedited, initial, and external.
• Clean claims are adjudicated in 30 days and paid within 30 days after that.
• Telehealth coverage follows in-person coverage.
• A provider paying a patient's premium is a rebate.