No NQTL may be imposed on MH/SUD in any classification unless WAC any processes, strategies, evidentiary standards or other factors used to apply the NQTL to MH/SUD benefits are in parity with those used to apply it to medical/surgical benefits in the same classification. Prohibited Benefits for actual treatment and services rendered may not be WAC Exclusions denied solely because a course of treatment was interrupted or was not completed. If a service is prescribed for a mental health condition and is WAC medically necessary, it may not be denied solely on the that it is part of a category of services or benefits that is excluded by the terms of the contract. Prohibited MH/SUD Benefits for MH/SUD may not be limited or denied based solely on WAC Exclusions Services age or condition. (Cont’d) (Cont’d) Medically necessary benefits for MH/SUD treatment may not be WAC denied solely because they were court ordered. Requirement WAC to Contract must provide benefits for neurodevelopmental therapies. Cover (Washington 2017 Base benchmark Plan subject to RCW 48.44.450(1)) Therapy O.S.T. v. Must provide benefits for mental health diagnoses (Diagnoses Therapy Regence; WAC listed in the DSM) without any “blanket limitations” (e.g., age six and under) O.S.T. v. Regence BlueShield, No. 88940-6 (WN October 9, 2014). Services covered must include physical, speech, and WAC occupational therapies. Benefits shall be payable only where the services have been RCW delivered pursuant to the referral and periodic review of a holder 48.21.310(2)) of a license issued pursuant to chapter 18.71 or 18.57 RCW or
WAC No NQTL may be imposed on MH/SUD in any classification unless any processes, strategies, evidentiary standards or other factors used to apply the NQTL to MH/SUD benefits are in parity with those used to apply it to medical/surgical benefits in the same classification. Prohibited Exclusions Prohibited Exclusions (Cont’d) WAC Benefits for actual treatment and services rendered may not be denied solely because a course of treatment was interrupted or was not completed. WAC If a service is prescribed for a mental health condition and is medically necessary, it may not be denied solely on the that it is part of a category of services or benefits that is excluded by the terms of the contract. MH/SUD Services WAC Benefits for MH/SUD may not be limited or denied based solely on age or condition. (Cont’d) WAC Medically necessary benefits for MH/SUD treatment may not be denied solely because they were court ordered. Therapy Requirement to Cover Therapy WAC Contract must provide benefits for neurodevelopmental therapies. (Washington 2017 Base benchmark Plan subject to RCW 48.44.450(1)) O.S.T. v. Regence; WAC Must provide benefits for mental health diagnoses (Diagnoses listed in the DSM) without any “blanket limitations” (e.g., age six and under) O.S.T. v. Regence BlueShield, No. 88940-6 (WN October 9, 2014). WAC Services covered must include physical, speech, and occupational therapies. RCW 48.21.310(2)) Benefits shall be payable only where the services have been delivered pursuant to the referral and periodic review of a holder of a license issued pursuant to chapter 18.71 or 18.57 RCW or