Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter P - MENTAL HEALTH PARITY
Division 3 - COMPLIANCE ANALYSIS FOR MH/SUD PARITY
Section 21.2436 - Quantitative Parity Analysis: Covered Benefits

Universal Citation: 28 TX Admin Code § 21.2436

Current through Reg. 50, No. 13; March 28, 2025

(a) General information. Within each QTL template, in the worksheet titled "Covered Benefits," an issuer must identify:

(1) whether outpatient benefits are subclassified into "office visit" and "other;"

(2) whether the plan or plan design has a tiered network; and

(3) if the plan or plan design has a tiered network, the number of tiers.

(b) List of covered benefits. In the worksheet titled "Covered Benefits," an issuer must list each benefit covered by the plan or plan design, including all benefits listed in the schedule of benefits and the policy, certificate, evidence of coverage, or contract of insurance. Covered benefits must be repeated as needed to list each benefit on separate lines, based on:

(1) network;

(2) types and levels of applicable financial requirements and QTLs; and

(3) classification or subclassification, as applicable.

(c) Combining covered benefits. Covered benefits that have the same QTLs may be combined for the purposes of the QTL analysis;

(d) Examples. The examples in this subsection illustrate the requirements of subsections (b) and (c) of this section.

(1) Example 1. If a plan or plan design covers the first office visit with $0 cost sharing, and subsequent office visits are subject to coinsurance, then each level of cost sharing must be listed on a separate line.

(2) Example 2. If a plan or plan design covers occupational therapy for both medical/surgical and MH/SUD diagnoses, then occupational therapy must be listed on separate lines for each.

(3) Example 3. If a plan or plan design covers physical therapy, occupational therapy, and speech therapy subject to identical QTLs, then the covered benefits may be combined in a single line.

(4) Example 4. If a plan or plan design applies identical types and levels of QTLs to all in-network medical/surgical and MH/SUD covered benefits, then all in-network medical/surgical covered benefits may be combined in a single line and all in-network MH/SUD covered benefits may be combined in a single line, for a total of two lines of covered benefits in each classification worksheet.

(e) Categorization, classification, and subclassification of covered benefits. For each covered benefit, the issuer must:

(1) categorize the covered benefit, consistent with the definitions of "medical/surgical benefit," "mental health benefit," and "substance use disorder benefit" in § 21.2406 of this title (relating to Definitions), as medical/surgical or MH/SUD;

(2) classify the covered benefit consistent with § 21.2408(b)(2)(A)(i) - (vi) of this title (relating to Parity Requirements with Respect to Financial Requirements and Treatment Limitations) as:
(A) inpatient, in-network;

(B) inpatient, out-of-network;

(C) outpatient, in-network;

(D) outpatient, out-of-network; and

(E) emergency care;

(3) if the issuer uses multiple network tiers, add separate subclassifications for in-network classifications, consistent with § 21.2408(c)(3)(B) of this title; and

(4) if applicable to outpatient benefits, subclassify the covered benefit, consistent with § 21.2408(c)(3)(C) of this title, as:
(A) outpatient, in-network including, if applicable, separate identification of:
(i) outpatient in-network office visits; and

(ii) all other outpatient in-network benefits; and

(B) outpatient, out-of-network, including, if applicable, separate identification of:
(i) outpatient out-of-network office visits; and

(ii) all other outpatient out-of-network benefits.

(f) Methodology for categorizing covered benefits. Within the QTL template, in the worksheet titled "Categorization Methodology," an issuer must provide an explanation of the methodology used to categorize a covered benefit as a mental health benefit, medical/surgical benefit, or substance use disorder benefit. If a plan defines a condition as a mental health condition, substance use disorder, or medical or surgical condition, it must categorize benefits for those conditions in the same way for purposes of this rule. For example, if a plan defines unspecified dementia as a mental health condition, it must categorize benefits for unspecified dementia as mental health benefits. An issuer must apply the same categorization for both the QTL and NQTL analyses.

(g) Methodology for classifying and subclassifying covered benefits. Within the QTL template, in the worksheet titled "Classification Methodology," an issuer must provide an explanation of the methodology used to classify and subclassify covered benefits, consistent with § 21.2408(b)(2) and (c)(3) of this title. In determining the classification in which a particular benefit belongs, an issuer must apply the same standards to medical/surgical benefits as to MH/SUD benefits. Plans and issuers must assign covered intermediate MH/SUD benefits (such as residential treatment, partial hospitalization, and intensive outpatient treatment) to the existing six classifications in the same way that they assign intermediate medical/surgical benefits to these classifications. For example, if a plan classifies care in skilled nursing facilities and rehabilitation hospitals for medical/surgical benefits as inpatient benefits, it must classify covered care in residential treatment facilities for MH/SUD benefits as inpatient benefits. If a plan treats home health care as an outpatient benefit, then any covered intensive outpatient MH/SUD services and partial hospitalization must be considered outpatient benefits as well. An issuer must apply its methodology consistently when classifying covered benefits and use the same classification for both the QTL and NQTL analyses.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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