Section 21.2409 - Nonquantitative Treatment Limitations(a) General requirement. A health benefit plan may not impose a nonquantitative treatment limitation with respect to mental health or substance use disorder benefits in any classification unless, under the terms of the plan as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health or substance use disorder benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical/surgical benefits in the classification.(b) Illustrative list of nonquantitative treatment limitations. Nonquantitative treatment limitations include: (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) formulary design for prescription drugs;(3) for plans with multiple network tiers (such as preferred providers and participating providers), network tier design;(4) standards for provider admission to participate in a network, including reimbursement rates;(5) plan methods for determining usual, customary, and reasonable charges;(6) 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);(7) exclusions based on failure to complete a course of treatment; and(8) 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.(c) Examples. The requirements of this section are illustrated by examples provided in figure 28 TAC § 21.2409(c). In each example, the health benefit plan is subject to the requirements of this section and provides both medical/surgical benefits and mental health and substance use disorder benefits. Attached Graphic
28 Tex. Admin. Code § 21.2409
Adopted by Texas Register, Volume 46, Number 36, September 3, 2021, TexReg 5579, eff. 9/7/2021