| (a) NQTLs in general. NQTLs generally are treatment
limitations on the scope or duration of benefits for treatment. An
issuer is prohibited from imposing NQTLs on MH/SUD benefits in any
classification unless, under the terms of the plan or coverage as
written and in operation, any processes, strategies, evidentiary standards,
or other factors used in applying the NQTL to MH/SUD benefits in a
classification are comparable to, and are applied no more stringently
than, those used in applying the limitation with respect to medical/surgical
benefits in the same classification.
(b) Numerical application of NQTLs. While NQTLs are
generally defined as treatment limitations that are not expressed
numerically, the application of an NQTL in a numerical way does not
modify its nonquantitative character. For example, standards for provider
admission to participate in a network are NQTLs because such standards
are treatment limitations that typically are not expressed numerically.
But these standards sometimes rely on numerical standards such as
numerical reimbursement rates. In this case, the numerical expression
of reimbursement rates does not modify the nonquantitative character
of the provider admission standards. Therefore, reimbursement rates
to which a participating provider must agree are to be evaluated in
accordance with the rules for NQTLs.
(c) Examples. The following is an illustrative, non-exhaustive
list of NQTLs:
(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) preauthorization or ongoing authorization requirements;
(3) concurrent review standards;
(4) formulary design for prescription drugs;
(5) for plans with multiple network tiers (such as
preferred providers and participating providers), network tier design;
(6) standards for provider admission to participate
in a network, including reimbursement rates;
(7) plan or issuer methods for determining usual, customary,
and reasonable charges;
(8) 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);
(9) exclusions of specific treatments for certain conditions;
(10) restrictions on applicable provider billing codes;
(11) standards for providing access to out-of-network
providers;
(12) exclusions based on failure to complete a course
of treatment; and
(13) 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.
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