Formulary design; methods for determining customary, and reasonable charges; Use of policies or step therapy protocols; Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit scope or duration of benefits A permanent exclusion of all benefits for a particular condition or disorder is not a NQTL; may be allowable if not otherwise prohibited Plan standards: in-and-out-of-network geographic limitations, limitations on inpatient services WAC for situations where the participant is a threat to self or others, exclusions for court-ordered and 284-43-994(2) involuntary holds, experimental treatment limitations, service coding, exclusions for services provided by clinical social workers, and network adequacy If a health plan or issuer classifies providers into and varies cost-sharing based on the WAC 284-43-992 different tiers, there must not be any financial requirement or treatment limitation on MH/SUD (6)(c and d) benefits that is more restrictive than what applies to substantially all medical/surgical benefits in that tier. No NQTL may be imposed on MH/SUD in any classification unless any processes, strategies, WAC evidentiary standards or other factors used to apply the NQTL to MH/SUD benefits are in parity 284-43-994(1) with those used to apply it to medical/surgical benefits in the same classification. WAC Benefits for actual treatment and services rendered may not be denied solely because a course of 284-43-995(1) treatment was interrupted or was not completed. Prohibited WAC If a service is prescribed for a mental health condition and is medically necessary, it may not be 284-43-995(2) Exclusions denied solely on the that it is part of a category of services or benefits that is excluded by the WAC terms of the contract. 284-43-995(3) Benefits for MH/SUD may not be limited or denied based solely on age or condition. WAC Medically necessary benefits for MH/SUD treatment may not be denied solely because they were 284-43-995(4) ordered.
WAC 284-43-994(2) WAC 284-43-992 (6)(c and d) WAC 284-43-994(1) Formulary design; methods for determining customary, and reasonable charges; Use of policies or step therapy protocols; Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit scope or duration of benefits A permanent exclusion of all benefits for a particular condition or disorder is not a NQTL; may be allowable if not otherwise prohibited Plan standards: in-and-out-of-network geographic limitations, 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, and network adequacy If a health plan or issuer classifies providers into and varies cost-sharing based on the different tiers, there must not be any financial requirement or treatment limitation on MH/SUD benefits that is more restrictive than what applies to substantially all medical/surgical benefits in that tier. 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 WAC 284-43-995(1) WAC 284-43-995(2) WAC 284-43-995(3) WAC 284-43-995(4) Benefits for actual treatment and services rendered may not be 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 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. Benefits for MH/SUD may not be limited or denied based solely on age or condition. Medically necessary benefits for MH/SUD treatment may not be denied solely because they were ordered.
checklist-forms-hmo-large-group.docx