Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 3 - COMPLIANCE ANALYSIS FOR MH/SUD PARITY › Section 21.2439 - Nonquantitative Treatment Limitations Generally

Current through Reg. 49, No. 28; July 12, 2024
(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.