DEFINITIONS

In this subchapter: (1) "Mental health benefit" means a benefit relating to an item or service for a mental health condition, as defined under the terms of a health benefit plan and in accordance with applicable federal and state law. (2) "Nonquantitative treatment limitation" means a limit on the scope or duration of treatment that is not expressed numerically. The term includes: (A) a medical management standard limiting or excluding benefits based on medical necessity or medical appropriateness or based on whether a treatment is experimental or investigational; (B) formulary design for prescription drugs; (C) network tier design; (D) a standard for provider participation in a network, including reimbursement rates; (E) a method used by a health benefit plan to determine usual, customary, and reasonable charges; (F) a step therapy protocol; (G) an exclusion based on failure to complete a course of treatment; and (H) a restriction based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of a benefit. (3) "Quantitative treatment limitation" means a treatment limitation that determines whether, or to what extent, benefits are provided based on an accumulated amount such as an annual or lifetime limit on days of coverage or number of visits. The term includes a deductible, a copayment, coinsurance, or another out-of-pocket expense or annual or lifetime limit, or another financial requirement. (4) "Substance use disorder benefit" means a benefit relating to an item or service for a substance use disorder, as defined under the terms of a health benefit plan and in accordance with applicable federal and state law.