Common NQTLs
| NQTL | Description | Parity Risk |
|---|---|---|
| Prior authorization | Requirement to obtain approval before receiving care | High — PA often required for MH/SUD but not medical |
| Step therapy | Requirement to try lower-cost treatments first | High — step therapy often more stringent for MH/SUD |
| Network adequacy | Standards for provider network size and access | High — MH/SUD networks often smaller than medical |
| Reimbursement rates | Rates paid to in-network providers | High — MH/SUD rates often lower, driving providers out-of-network |
| Fail-first protocols | Requirement to fail on one treatment before another is covered | Medium — may be more stringent for MH/SUD |
The Comparative Analysis Framework
The NQTL comparative analysis must: (1) identify the NQTL; (2) identify the factors used to apply the NQTL; (3) identify the evidentiary standards used; (4) demonstrate that the factors and standards are applied comparably to MH/SUD and medical/surgical benefits; and (5) demonstrate that the NQTL does not result in more restrictive access to MH/SUD benefits.
Outcomes Data Requirement
Compliance Note
Per FAB 2026-03, the comparative analysis must now include outcomes data demonstrating that the NQTL does not result in more restrictive access to MH/SUD benefits in practice. Key outcomes metrics: prior authorization approval rates (MH/SUD vs. medical/surgical), network out-of-network utilization rates, and provider reimbursement rates. Plans with significantly worse MH/SUD outcomes will be presumed to be in violation.