3 Colo. Code Regs. § 702-4-2-64-7
Current through Register Vol. 47, No. 24, December 25, 2024
Section 3 CCR 702-4-2-64-7 - Non-Quantitative Treatment LimitationsA. Carriers shall not impose a non-quantitative treatment limitation with respect to behavioral, mental health, and substance use disorder benefits in any classification unless, under the terms of the coverage as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the non-quantitative treatment limitation to behavioral, 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. Examples of non-quantitative treatment limitations include, but are not limited to: 1. Medical management standards limiting or excluding benefits based on:a. Medical necessity or medical appropriateness; orb. Whether the treatment is experimental or investigational.2. Step therapy or fail-first protocols;3. Exclusions based on failure to complete a course of treatment;4. Restrictions based on: c. Provider specialty; andd. Other criteria that limit the scope or duration of benefits.5. Formulary design for prescription drugs;6. Network tier design (when the plan has multiple network tiers);7. Standards for provider admission to a network, including reimbursement rates; and8. Methods for determining usual, customary, and reasonable charges.C. Allowable Non-Quantitative Treatment Limitations1. Carriers may utilize the following non-exhaustive standards when applying non-quantitative treatment limitations:a. Medical management standards may be used, as long as the criteria are comparable, and applied no more stringently than for behavioral, mental health, and substance use disorder benefits than for medical/surgical benefits;b. Formulary design may be used, as long as the criteria used for behavioral mental health, and substance use disorder benefits are comparable, and applied no more stringently than for medical/surgical benefits; andc. Network design may be used, as long as the criteria used for behavioral, mental health, and substance use disorder benefits are comparable, and applied no more stringently than for medical/surgical benefits that comply with state network adequacy requirements.D. Non-Quantitative Treatment Limitation Violations1. Notwithstanding Subsection C.1.A, carriers shall not use the following medical management standards when applying limitations to behavioral, mental health, and substance use disorder benefits:a. The carrier routinely approves a number of days without a treatment plan for medical/surgical inpatient services, but approves, on a routine basis, a lesser number of days without a treatment plan for behavioral, mental health, and substance use disorders.b. The carrier applies concurrent review to inpatient stays with various lengths of stay due to the medical condition, but reviews all behavioral, mental health, and substance use disorder inpatient stays using a more restrictive review criteria, reviewing the stay more frequently in all cases than commonly used for medical/surgical benefits.c. Location of Services (1) The carrier allows for out-of-state treatment of medical/surgical services, but does not permit out-of-state treatment for behavioral, mental health, and substance use disorder services; or(2) Permits access to a non-network hospital for medical/surgical services, but does not permit access to a non-network hospital for behavioral, mental health, and substance use disorders, when the plan covers non-network services.d. The carrier does not apply a payment reduction penalty to outpatient medical/surgical services that do not have prior authorization, but applies a penalty to all outpatient behavioral, mental health, and substance use disorder benefits when no prior authorization has been obtained.e. Employee Assistance Programs (Group Plans Only) The carrier requires that the member utilize the available Employee Assistance Program benefits prior to utilizing the behavioral, mental health, and substance use disorder benefits under the group plan. The carrier does not require the member to utilize the Employee Assistance Program for any medical/surgical benefits prior to utilizing the group plan.
2. Carriers shall not use the following pharmacy benefits when applying limitations to behavioral, mental health, and substance use disorder benefits: a. Carrier formulary design for coverage of prescription drugs for medical/surgical conditions is based on FDA approval, clinical studies, peer-reviewed medical literature, recommendations of experts with necessary training and experience and other medical decision criteria which are routinely provided, whereas the exclusion of behavioral, mental health, and substance use disorder drugs is only based on the side effects reported as a part of clinical studies.b. A carrier regularly provides coverage for medical/surgical prescription drugs on all four (4) tiers of a four (4) tier formulary design, but places all drugs for the treatment of behavioral, mental health, and substance use disorders on the two (2) highest tiers, without regard to it being generic, preferred brand name or non-preferred brand name.3. Carriers shall not use the following network designs when applying limitations to behavioral, mental health, and substance use disorder benefits: a. The carrier regularly allows licensed non-M.D. providers into the network while not permitting a licensed non-M.D. provider into the network who primarily treats behavioral, mental health, or substance use disorders.b. The carrier regularly negotiates with a medical/surgical provider based on the rates for behavioral, mental health, and substance use disorder providers.4. The items in this section are not an exhaustive list of non-quantitative treatment limitation violations.37 CR 11, June 10, 2014, effective 7/1/201437 CR 12, June 25, 2014, effective 7/15/2014Colorado Register, Vol 37, No. 14. July 25, 2014, effective 8/15/201437 CR 23, December 10, 2014, effective 1/1/201538 CR 03, February 10, 2015, effective 3/15/201538 CR 06, March 25, 2015, effective 4/30/201538 CR 09, May 10, 2015, effective 6/1/201538 CR 13, July 10, 2015, effective 7/30/201538 CR 19, October 10, 2015, effective 11/1/201538 CR 21, November 10, 2015, effective 1/1/201638 CR 23, December 10, 2015, effective 1/1/201639 CR 01, January 10, 2016, effective 2/1/201639 CR 05, March 10, 2016, effective 4/1/201639 CR 08, April 25, 2016, effective 5/15/201639 CR 19, October 10, 2016, effective 11/1/201639 CR 20, October 25, 2016, effective 1/1/201739 CR 22, November 25, 2016, effective 1/1/201739 CR 23, December 10, 2016, effective 1/1/201739 CR 23, December 25, 2016, effective 1/1/201740 CR 03, February 10, 2017, effective 3/15/201740 CR 09, May 10, 2017, effective 6/1/201740 CR 15, August 10, 2017, effective 9/1/201740 CR 17, September 10, 2017, effective 10/1/201740 CR 21, November 10, 2017, effective 12/1/201741 CR 04, February 25, 2018, effective 4/1/201841 CR 05, March 10, 2018, effective 6/1/201841 CR 08, April 25, 2018, effective 6/1/201841 CR 09, May 10, 2018, effective 6/1/201841 CR 11, June 10, 2018, effective 7/1/201841 CR 15, August 10, 2018, effective 9/1/201841 CR 17, September 10, 2018, effective 10/1/201841 CR 18, September 25, 2018, effective 10/15/201841 CR 21, November 10, 2018, effective 12/1/201841 CR 23, December 10, 2018, effective 1/1/201942 CR 01, January 10, 2019, effective 2/1/201941 CR 19, October 10, 2018, effective 3/1/201942 CR 03, February 10, 2019, effective 4/1/201942 CR 04, February 25, 2019, effective 4/1/201942 CR 06, March 25, 2019, effective 6/1/201942 CR 08, April 10, 2019, effective 6/1/201942 CR 15, August 10, 2019, effective 9/1/201942 CR 17, September 10, 2019, effective 10/1/201943 CR 02, January 25, 2020, effective 12/20/201943 CR 02, January 25, 2020, effective 12/23/201942 CR 23, December 10, 2019, effective 1/1/202043 CR 01, January 10, 2020, effective 2/1/202042 CR 24, December 25, 2019, effective 2/2/202043 CR 06, March 25, 2020, effective 4/15/202043 CR 10, May 25, 2020, effective 8/1/202043 CR 14, July 25, 2020, effective 8/15/202043 CR 17, September 10, 2020, effective 10/1/202043 CR 18, September 25, 2020, effective 11/1/202043 CR 22, November 25, 2020, effective 12/15/202043 CR 24, December 25, 2020, effective 1/15/202144 CR 03, February 10, 2021, effective 3/15/202144 CR 08, April 25, 2021, effective 5/15/202144 CR 09, May 10, 2021, effective 6/1/202144 CR 10, May 25, 2021, effective 6/14/202144 CR 10, May 25, 2021, effective 6/15/202144 CR 13, July 10, 2021, effective 8/1/202144 CR 15, August 10, 2021, effective 9/1/202144 CR 19, October 10, 2021, effective 11/1/202144 CR 21, November 10, 2021, effective 12/1/202144 CR 23, December 10, 2021, effective 12/30/202144 CR 21, November 10, 2021, effective 1/1/202244 CR 23, December 10, 2021, effective 1/15/202244 CR 24, December 25, 2021, effective 1/15/202245 CR 03, February 10, 2022, effective 3/2/202245 CR 08, April 25, 2022, effective 5/30/202245 CR 09, May 10, 2022, effective 5/30/202245 CR 10, May 25, 2022, effective 6/14/202245 CR 11, June 10, 2022, effective 6/30/202245 CR 11, June 10, 2022, effective 7/15/202245 CR 19, October 10, 2022, effective 11/1/202245 CR 20, October 25, 2022, effective 11/14/202245 CR 21, November 10, 2022, effective 11/30/202245 CR 24, December 25, 2022, effective 1/14/202346 CR 01, January 10, 2023, effective 2/14/202346 CR 06, March 25, 2023, effective 2/15/202346 CR 03, February 10, 2022, effective 3/2/202346 CR 04, February 25, 2023, effective 3/17/202346 CR 05, March 10, 2023, effective 4/15/202346 CR 09, May 10, 2023, effective 5/30/202346 CR 09, May 10, 2023, effective 6/1/202346 CR 10, May 25, 2023, effective 6/15/202346 CR 11, June 10, 2023, effective 6/30/2023