| (a) Deadline for quantitative parity analyses. An issuer
must complete the parity analyses of its quantitative treatment limitations
(QTLs) required by this division for each existing plan not later
than the 180th day after the effective date of this subchapter.
(b) Phase-in for nonquantitative parity analyses. The
deadlines for completing the parity analyses of an issuer's nonquantitative
treatment limitations (NQTLs) will be phased in over three years,
in the following manner:
(1) Not later than June 1, 2022, an issuer must complete
its initial analysis of each of its utilization review-related NQTLs,
including:
(A) medical management standards limiting or excluding
benefits based on medical necessity or medical appropriateness, or
based on whether the treatment is experimental or investigative;
(B) 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);
(C) exclusions based on failure to complete a course
of treatment;
(D) preauthorization or ongoing authorization requirements;
and
(E) concurrent review standards.
(2) Not later than June 1, 2023, an issuer must complete
its initial analysis of each of its network-adequacy-related NQTLs,
including:
(A) for plans with multiple network tiers (such as
preferred providers and participating providers), network tier design;
(B) standards for provider admission to participate
in a network, including reimbursement rates;
(C) plan methods for determining usual, customary,
and reasonable charges;
(D) 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; and
(E) standards for providing access to out-of-network
providers.
(3) Not later than June 1, 2024, an issuer must complete
its initial analysis of all of its remaining NQTLs, including:
(A) formulary design for prescription drugs;
(B) exclusions of specific treatments for certain conditions;
and
(C) restrictions on applicable provider billing codes.
(4) Before marketing new plans during the phase-in
period, an issuer must have completed its analysis of all NQTLs for
which the deadline has passed.
(c) New plans. An issuer must perform both its quantitative
and nonquantitative analyses before marketing a new plan.
(d) Modified plans. An issuer must update its analyses
within 30 days of each material change to a QTL or an NQTL.
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