(Cont’d) Use of fail-first policies or step therapy protocols; (f) Exclusions based on failure to complete a course of treatment; (g) and Restrictions based on geographic location, facility type, (h) provider specialty, and other criteria that limit scope or duration of benefits. A permanent exclusion of all benefits for a particular condition or WAC disorder is not an NQTL; may be allowable if not otherwise prohibited. (See definition of “Treatment Limitations”) All health plan standards must comply with the parity WAC requirement. Includes: 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 and involuntary holds, experimental treatment limitations, service coding, exclusions for services provided by clinical social workers, and network adequacy. Mental Health Mental If a health plan or issuer classifies providers into and varies WAC and Substance Health Parity based on the different tiers, no financial requirement or Use Disorder (Cont’d) treatment limitation on MH/SUD benefits may be more restrictive WAC Services, than what applies to substantially all medical/surgical benefits in that tier. Including No NQTL may be imposed on MH/SUD in any classification unless WAC Behavioral any processes, strategies, evidentiary standards or other factors used Health to apply the NQTL to MH/SUD benefits are in parity with those used Treatment to apply it to medical/surgical benefits in the same classification. (EHB) Prohibited Benefits for actual treatment and services rendered may not be WAC (Cont’d) Exclusions denied solely because a course of treatment was interrupted or was not completed.
(Cont’d) (f) Use of fail-first policies or step therapy protocols; (g) Exclusions based on failure to complete a course of treatment; and (h) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit scope or duration of benefits. WAC A permanent exclusion of all benefits for a particular condition or disorder is not an NQTL; may be allowable if not otherwise prohibited. (See definition of “Treatment Limitations”) WAC All health plan standards must comply with the parity requirement. Includes: 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 and involuntary holds, experimental treatment limitations, service coding, exclusions for services provided by clinical social workers, and network adequacy. Mental Health and Substance Use Disorder Services, Mental Health Parity (Cont’d) WAC WAC If a health plan or issuer classifies providers into and varies based on the different tiers, no financial requirement or treatment limitation on MH/SUD benefits may be more restrictive than what applies to substantially all medical/surgical benefits in that tier. Including Behavioral Health Treatment 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. (EHB) (Cont’d) Prohibited Exclusions WAC Benefits for actual treatment and services rendered may not be denied solely because a course of treatment was interrupted or was not completed.
checklist-forms-2018-disability-sg-analyst-checklist.docx