| (a) General requirement. A health benefit plan may
not impose a nonquantitative treatment limitation with respect to
mental health or substance use disorder benefits in any classification
unless, under the terms of the plan as written and in operation, any
processes, strategies, evidentiary standards, or other factors used
in applying the nonquantitative treatment limitation to mental health
or substance use disorder benefits in the classification are comparable
to, and are applied no more stringently than, the processes, strategies,
evidentiary standards, or other factors used in applying the limitation
with respect to medical/surgical benefits in the classification.
(b) Illustrative list of nonquantitative treatment
limitations. Nonquantitative treatment limitations include:
(1) medical management standards limiting or excluding
benefits based on medical necessity or medical appropriateness, or
based on whether the treatment is experimental or investigative;
(2) formulary design for prescription drugs;
(3) for plans with multiple network tiers (such as
preferred providers and participating providers), network tier design;
(4) standards for provider admission to participate
in a network, including reimbursement rates;
(5) plan methods for determining usual, customary,
and reasonable charges;
(6) refusal to pay for higher-cost therapies until
it can be shown that a lower-cost therapy is not effective (also known
as fail-first policies or step therapy protocols);
(7) exclusions based on failure to complete a course
of treatment; and
(8) restrictions based on geographic location, facility
type, provider specialty, and other criteria that limit the scope
or duration of benefits provided under the plan or coverage.
(c) Examples. The requirements of this section are
illustrated by examples provided in figure 28 TAC §21.2409(c).
In each example, the health benefit plan is subject to the requirements
of this section and provides both medical/surgical benefits and mental
health and substance use disorder benefits.
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