new text begin Nonquantitative treatment limitations or NQTLs. new text end

new text begin "Nonquantitative treatment limitations" or "NQTLs" means processes, strategies, or evidentiary standards, or other factors that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. NQTLs include but are not limited to: new text end

new text begin (1) medical management standards limiting or excluding benefits based on (i) medical necessity or medical appropriateness, or (ii) whether the treatment is experimental or investigative; new text end

new text begin (2) formulary design for prescription drugs; new text end

new text begin (3) health plans with multiple network tiers; new text end

new text begin (4) criteria and parameters for provider inclusion in provider networks, including credentialing standards and reimbursement rates; new text end

new text begin (5) health plan methods for determining usual, customary, and reasonable charges; new text end

new text begin (6) fail-first or step therapy protocols; new text end

new text begin (7) exclusions based on failure to complete a course of treatment; new text end

new text begin (8) 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 health plan; new text end

new text begin (9) in- and out-of-network geographic limitations; new text end

new text begin (10) standards for providing access to out-of-network providers; new text end

new text begin (11) limitations on inpatient services for situations where the enrollee is a threat to self or others; new text end

new text begin (12) exclusions for court-ordered and involuntary holds; new text end

new text begin (13) experimental treatment limitations; new text end

new text begin (14) service coding; new text end

new text begin (15) exclusions for services provided by clinical social workers; and new text end

new text begin (16) provider reimbursement rates, including rates of reimbursement for mental health and substance use disorder services in primary care. new text end