Non-quantitative treatment limitations (NQTLs) are limitations that are Sec. 302. not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. NQTLs include, but are not limited to: Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative Formulary design for prescription drugs For plans with multiple network tiers (such as preferred providers and participating providers), network tier design Standards for provider admission to participate in a network, including reimbursement rates Plan methods for determining usual, customary, and reasonable charges Refusal to pay for higher-cost therapies until it can be shown that a therapy is not effective (also known as fail-first policies or step therapy protocols) Exclusions based on failure to complete a course of treatment Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage In and out of network geographic limitations Standards for providing access to out-of-network providers Limitations on inpatient services for situations where the participant is a threat to self or others Exclusions for court-ordered and involuntary holds Experimental treatment limitations Service coding Exclusions for services provided by clinical social workers Network adequacy Provider reimbursement rates, including rates of reimbursement for mental health and substance use services in primary care Sec. 303. For any utilization review or benefit determination for the treatment of a substance use disorder, including but not limited to prior authorization and medical necessity determinations, the clinical review criteria shall be the most recent Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine. No additional criteria may be used during utilization review or benefit determination for treatment of substance use disorders. Additional and more extensive provisions are available for this title and all other titles. Contact ParityTrack Policy Director, Tim Clement at . TITLE IV: Extending State Parity Protections to Medicaid
Sec. 302. Non-quantitative treatment limitations (NQTLs) are limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. NQTLs include, but are not limited to: Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative Formulary design for prescription drugs For plans with multiple network tiers (such as preferred providers and participating providers), network tier design Standards for provider admission to participate in a network, including reimbursement rates Plan methods for determining usual, customary, and reasonable charges Refusal to pay for higher-cost therapies until it can be shown that a therapy is not effective (also known as fail-first policies or step therapy protocols) Exclusions based on failure to complete a course of treatment Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage In and out of network geographic limitations Standards for providing access to out-of-network providers Limitations on inpatient services for situations where the participant is a threat to self or others Exclusions for court-ordered and involuntary holds Experimental treatment limitations Service coding Exclusions for services provided by clinical social workers Network adequacy Provider reimbursement rates, including rates of reimbursement for mental health and substance use services in primary care Sec. 303. For any utilization review or benefit determination for the treatment of a substance use disorder, including but not limited to prior authorization and medical necessity determinations, the clinical review criteria shall be the most recent Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine. No additional criteria may be used during utilization review or benefit determination for treatment of substance use disorders. Additional and more extensive provisions are available for this title and all other titles. Contact ParityTrack Policy Director, Tim Clement at . TITLE IV: Extending State Parity Protections to Medicaid