reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2402 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
(a) Plans subject to this subchapter. This
					 subchapter applies to all health benefit plans subject to Insurance Code
					 Chapter 1355, Subchapter F, concerning Coverage for Mental Health Conditions
					 and Substance Use Disorders. Health benefit plans subject to Insurance Code
					 Chapter 1355, Subchapter F, are plans that provide benefits or coverage for
					 treatment expenses incurred as a result of a mental health condition or offer
					 mental health or substance use disorder benefits, whether as mandatory coverage
					 under Insurance Code Chapter 1355, concerning Benefits for Certain Mental
					 Disorders, or under another Insurance Code chapter, or as optional coverage
					 (for instance, in an individual short-term limited duration plan).
(b) Excepted plans. This subchapter does not
					 apply to a plan that is excepted from:
(1)
					 Insurance Code Chapter 1355, Subchapter F, as identified in Insurance Code
					 §
												1355.253, concerning
					 Exceptions; or
(2) Insurance Code
					 Chapter 1425, concerning Application of Subtitle to Certain Coverage, as
					 identified in Insurance Code §
												1425.001,
					 concerning Exemption from Application of Subtitle.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2403 - Coordination of Statutory Language

Current through Reg. 49, No. 28; July 12, 2024
Restrictions on coverage limitations. If a provision of
						the Insurance Code or Texas Department of Insurance regulations allows a health
						benefit plan issuer to place quantitative or nonquantitative treatment
						limitations on coverage for mental health and substance use disorder
						conditions, an issuer may apply the limitation only to the extent that the
						limitation does not violate the parity requirements of Insurance Code Chapter
						1355, Subchapter F, concerning Coverage for Mental Health Conditions and
						Substance Use Disorders, and this subchapter.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2404 - Differences from Federal Rules

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Global substitution of terms. This subchapter substitutes the following terms
					 for terms used in
					 45 CFR
					 §
												146.136 (concerning Parity in Mental
					 Health and Substance Use Disorder Benefits) with no change in meaning:
(1) the term "enrollees" is substituted for
					 the term "participants and beneficiaries";
(2) the term "health benefit plan" is
					 substituted for the terms "group health plan" (or health insurance coverage
					 offered in connection with such plans) and "plan or coverage"; and
(3) the terms "requirement" or "requirements"
					 are substituted for the terms "rule" or "rules."
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2405 - Corrective Action; Severability

Current through Reg. 49, No. 28; July 12, 2024
(a) The
					 department may require the issuer to:
(1)
					 submit a corrective action plan to correct deficiencies in the issuer's
					 submissions and analyses under Divisions 2 and 3 of this subchapter. The
					 corrective action plan will specify the actions the issuer will take to comply
					 with this subchapter; or
(2) notify
					 all individuals enrolled in the applicable plan or plans that such coverage
					 does not comply with this subchapter; or
(3) a combination of the actions described in
					 paragraphs (1) and (2) of this subsection.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2406 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
Definitions. For purposes of this subchapter, the
						following terms have the meanings indicated, except where the context clearly
						indicates otherwise:
(1)
					 Administrative denial--A denial of a claim that is not an adverse
					 determination, including, but not limited to, denials of claims for noncovered
					 benefits, duplicate claims, incorrect billing, and because an individual is not
					 an enrollee.
(2) Adverse
					 determination--A determination by a health benefit plan or utilization review
					 agent that health care services or benefits provided or proposed to be provided
					 to an enrollee are not medically necessary, appropriate, or are experimental or
					 investigational. Consistent with Insurance Code Chapter 1369, concerning
					 Benefits Related to Prescription Drugs and Devices and Related Services, the
					 following are adverse determinations:
(A) a
					 denial of a fail-first (or step therapy) protocol exception request;
					 and
(B) an issuer's refusal to
					 treat the drug as a covered benefit, if an enrollee's physician has determined
					 that a drug is medically necessary and the drug is not included in the
					 enrollee's plan formulary.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2407 - Parity Requirements with Respect to Aggregate Lifetime and Annual Dollar Limits

Current through Reg. 49, No. 28; July 12, 2024
This section details application of the parity
						requirements under this subchapter with respect to aggregate lifetime and
						annual dollar limits that may be permitted by state or federal law.
(1) General parity requirement. A health
					 benefit plan that provides both medical/surgical benefits and MH/SUD benefits
					 must comply with paragraph (2), (3), or (5) of this section, as
					 applicable.
(2) Plan with no limit
					 or limits on less than one-third of all medical/surgical benefits. If a health
					 benefit plan does not include an aggregate lifetime or annual dollar limit on
					 any medical/surgical benefits or includes an aggregate lifetime or dollar limit
					 that applies to less than one-third of all medical/surgical benefits, it may
					 not impose an aggregate lifetime or annual dollar limit, respectively, on
					 mental health or substance use disorder benefits.
(3) Plan with a limit on at least two-thirds
					 of all medical/surgical benefits. If a health benefit plan includes an
					 aggregate lifetime or annual dollar limit on at least two-thirds of all
					 medical/surgical benefits, it must either:
(A)
					 apply the aggregate lifetime or annual dollar limit both to the
					 medical/surgical benefits to which the limit would otherwise apply and to
					 MH/SUD benefits in a manner that does not distinguish between the
					 medical/surgical benefits and MH/SUD benefits; or
(B) not include an aggregate lifetime or
					 annual dollar limit on mental health or substance use disorder benefits that is
					 less than the aggregate lifetime or annual dollar limit, respectively, on
					 medical/surgical benefits. (Some cumulative financial requirements and
					 cumulative quantitative treatment limitations other than aggregate lifetime or
					 annual dollar limits are prohibited in § 21.2408 of this title (relating
					 to Parity Requirements with Respect to Financial Requirements and Treatment
					 Limitations).)
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2408 - Parity Requirements with Respect to Financial Requirements and Treatment Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Clarification of terms.
(1) Classification of
					 benefits. When reference is made in this subchapter to a classification of
					 benefits, the term "classification" means a classification as described in
					 subsection (b)(2) of this section.
(2) Type of financial requirement or
					 treatment limitation. When reference is made in this subchapter to a type of
					 financial requirement or treatment limitation, the reference to type means its
					 nature. Different types of financial requirements include deductibles,
					 copayments, coinsurance, and out-of-pocket maximums. Different types of
					 quantitative treatment limitations include annual, episode, and lifetime day
					 and visit limits. An illustrative list of nonquantitative treatment limitations
					 is provided in § 21.2409(b) of this title (relating to Nonquantitative
					 Treatment Limitations).
(3) Level
					 of a type of financial requirement or treatment limitation. When reference is
					 made in this subchapter to a level of a type of financial requirement or
					 treatment limitation, "level" refers to the magnitude of the type of financial
					 requirement or treatment limitation. For example, different levels of
					 coinsurance include 20% and 30%, different levels of a copayment include $15
					 and $20, different levels of a deductible include $250 and $500, and different
					 levels of an episode limit include 21 inpatient days per episode and 30
					 inpatient days per episode.
(4)
					 Coverage unit. When reference is made in this subchapter to a coverage unit,
					 "coverage unit" refers to the way in which a health benefit plan groups
					 individuals for purposes of determining benefits, or premiums or contributions.
					 For example, different coverage units include self-only, family, and
					 employee-plus-spouse.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2409 - Nonquantitative Treatment Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 General requirement. A health benefit plan may not impose a nonquantitative
					 treatment limitation with respect to mental health or substance use disorder
					 benefits in any classification unless, under the terms of the plan as written
					 and in operation, any processes, strategies, evidentiary standards, or other
					 factors used in applying the nonquantitative treatment limitation to 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) Illustrative list of nonquantitative
					 treatment limitations. Nonquantitative treatment limitations include:
(1) medical management standards limiting or
					 excluding benefits based on medical necessity or medical appropriateness, or
					 based on whether the treatment is experimental or investigative;
(2) formulary design for prescription
					 drugs;
(3) for plans with multiple
					 network tiers (such as preferred providers and participating providers),
					 network tier design;
(4) standards
					 for provider admission to participate in a network, including reimbursement
					 rates;
(5) plan methods for
					 determining usual, customary, and reasonable charges;
(6) refusal to pay for higher-cost therapies
					 until it can be shown that a lower-cost therapy is not effective (also known as
					 fail-first policies or step therapy protocols);
(7) exclusions based on failure to complete a
					 course of treatment; and
(8)
					 restrictions based on geographic location, facility type, provider specialty,
					 and other criteria that limit the scope or duration of benefits provided under
					 the plan or coverage.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2411 - Availability of Plan Information

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Criteria for medical necessity determinations. The criteria for medical
					 necessity determinations made under a health benefit plan with respect to
					 mental health or substance use disorder benefits must be made available by the
					 issuer to any enrollee or contracting provider upon request, consistent with
					 Insurance Code Chapters 843 and 1301.
(b) Reason for denial. The reason for any
					 denial under a health benefit plan with respect to mental health or substance
					 use disorder benefits in the case of any enrollee must be made available by the
					 issuer in a form and manner consistent with Insurance Code §
											4201.303,
					 concerning Adverse Determination: Contents of Notice.
(c) Provisions of other law. Compliance with
					 the disclosure requirements in subsections (a) and (b) of this section is not
					 determinative of compliance with any other provision of applicable federal or
					 state law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2413 - Sale of Nonparity Health Benefit Plans

Current through Reg. 49, No. 28; July 12, 2024
An issuer may not sell a health benefit plan, policy,
						certificate, or contract of insurance that fails to comply with §
											21.2407
						of this title (relating to Parity Requirements with Respect to Aggregate
						Lifetime and Annual Dollar Limits), § 21.2408 of this title (relating to
						Parity Requirements with Respect to Financial Requirements and Treatment
						Limitations), and § 21.2409 of this title (relating to Nonquantitative
						Treatment Limitations).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 1 - GENERAL PROVISIONS AND PARITY REQUIREMENTS › Section 21.2414 - Source-of-Injury Exclusions

Current through Reg. 49, No. 28; July 12, 2024
(a) No denial of
					 benefits. If a health benefit plan generally provides benefits for a type of
					 injury, the plan may not deny benefits otherwise provided for treatment of the
					 injury if the injury results from an act of domestic violence or a medical
					 condition (including both physical and mental health conditions). This rule
					 applies in the case of an injury resulting from a medical condition even if the
					 condition is not diagnosed before the injury.
(b) Example. The requirements of subsection
					 (a) of this section are illustrated by the example in figure 28 TAC §
					 21.2414(b).
Attached Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 2 - PLAN INFORMATION AND DATA COLLECTION › Section 21.2421 - Definitions - Division 2

Current through Reg. 49, No. 28; July 12, 2024
Definitions for Division 2. For purposes of Division 2 of
						this subchapter, the following terms have the meanings indicated, except where
						the context clearly indicates otherwise:
(1) Emergency care--A health care service or
					 benefit:
(A) provided in an air, land, or
					 water ambulance, and that is emergency care as defined under Insurance Code
					 Chapter 1201; or
(B) that meets a
					 plan's applicable statutory definition of emergency care in Insurance Code
					 Chapters 843, 1201, or 1301, or emergency care as required in Insurance Code
					 §
												1271.155, provided
					 in a hospital emergency facility, licensed freestanding emergency medical care
					 facility, community mental health center, or comparable emergency
					 facility.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 2 - PLAN INFORMATION AND DATA COLLECTION › Section 21.2422 - Deadline for Reporting Data

Current through Reg. 49, No. 28; July 12, 2024
Annual reporting. The information and data an issuer must
						report as required by Division 2 of this subchapter are due annually.
(1) Each reporting period is a calendar
					 year.
(2) The first reporting date
					 for this subchapter is December 1, 2021, for data from January 1, 2020, through
					 December 31, 2020.
(3) An issuer's
					 annual reports for calendar year 2021 and subsequent reporting periods are due
					 not later than July 1 following the reporting period.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 2 - PLAN INFORMATION AND DATA COLLECTION › Section 21.2423 - Collecting and Reporting Data

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Requirement to collect and report data. An issuer must collect and report the
					 data required by this division for each applicable health benefit plan using
					 the data collection template titled "MH/SUD Parity Rule Division 2 Data
					 Collection Reporting Form," consisting of multiple worksheets, published on
					 TDI's website.
(b) Separate
					 templates required. For each combination of plan type and market type the
					 issuer offers, the data must be reported in a separate template with its own
					 worksheets.
(c) Example. An example
					 of how subsection (b) of this section would be satisfied is that an issuer
					 offering PPO plans and EPO plans in the individual, small, and large group
					 markets will submit a separate template with its own worksheets for its PPO
					 individual plans, its PPO small group plans, and its PPO large group plans, and
					 another three files for its EPO plans, for a total submission of six templates
					 with their own worksheets.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 2 - PLAN INFORMATION AND DATA COLLECTION › Section 21.2424 - Issuer and Plan Information

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Identifying issuer information. For each data collection template an issuer
					 provides to TDI under § 21.2423 of this title (relating to Collecting and
					 Reporting Data), within the "MH/SUD Parity Rule Division 2 Data Collection
					 Reporting Form" template, in the worksheet titled "Issuer and Plan
					 Information," an issuer must provide the:
(1)
					 issuer name;
(2) NAIC number, or if
					 none, issuer license number;
(3)
					 reporting year;
(4) submission
					 date;
(5) contact name;
(6) title;
(7) phone number; and
(8) email address.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 2 - PLAN INFORMATION AND DATA COLLECTION › Section 21.2425 - Claims and Utilization Review: Reporting Classifications

Current through Reg. 49, No. 28; July 12, 2024
(a) Separate reporting. Within the "MH/SUD
					 Parity Rule Division 2 Data Collection Reporting Form" template, in the
					 worksheet titled "Claims and Utilization Review," an issuer must separately
					 report claims and requests for utilization review for medical/surgical and
					 MH/SUD.
(b) ICD diagnosis codes. In
					 the worksheet titled "Claims and Utilization Review," all claims and
					 utilization review requests with mental, behavioral, and neurodevelopmental
					 disorder diagnosis codes in the International Classification of Diseases and
					 Related Health Problems should be categorized as MH/SUD. Claims and utilization
					 review requests with all other ICD diagnostic codes should be categorized as
					 medical/surgical.
(c) Reporting
					 classifications. Claims and requests for utilization review are to be
					 identified in the worksheet as belonging in one the following reporting
					 classifications:
(1) inpatient,
					 in-network;
(2) inpatient,
					 out-of-network;
(3) outpatient,
					 in-network, consisting of:
(A) office visits;
					 and
(B) all other;
(4) outpatient, out-of-network,
					 consisting of:
(A) office visits;
					 and
(B) all other;
(5) emergency; and
(6) prescription drugs.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 2 - PLAN INFORMATION AND DATA COLLECTION › Section 21.2426 - Claims and Utilization Review: Aggregate Data Fields

Current through Reg. 49, No. 28; July 12, 2024
Within the "MH/SUD Parity Rule Division 2 Data Collection
						Reporting Form" template, in the worksheet titled "Claims and Utilization
						Review," for medical/surgical, MH/SUD, and for each of the classifications
						listed in § 21.2425(c) of this title (relating to Claims and Utilization
						Review: Reporting Classifications), an issuer must provide the following
						aggregate claims and utilization review data for the reporting year:
(1) the number of reported claims for
					 services or benefits that have been provided:
(A) in total;
(B) by out-of-network providers that were
					 covered as in-network benefits;
(C)
					 that were approved;
(D) that were
					 administratively denied; and
(E)
					 that were adversely determined;
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 2 - PLAN INFORMATION AND DATA COLLECTION › Section 21.2427 - Plan Reimbursement Rates Compared with Medicare Rates

Current through Reg. 49, No. 28; July 12, 2024
(a) Reporting worksheet. An issuer must
					 report the data required by this section within the "MH/SUD Parity Rule
					 Division 2 Data Collection Reporting Form" template in the worksheet titled
					 "Reimbursement Rates."
(b)
					 Categories of providers and billing codes. An issuer must report average plan
					 reimbursement rates separately for in-network and out-of-network providers for
					 services provided by the following categories of providers for the billing
					 codes specified by TDI in the worksheet:
(1)
					 orthopedic surgeons;
(2)
					 cardiologists;
(3)
					 internists;
(4)
					 endocrinologists;
(5)
					 gastroenterologists;
(6)
					 neurologists;
(7)
					 pediatricians;
(8)
					 dermatologists;
(9)
					 psychiatrists;
(10)
					 psychologists;
(11) licensed
					 clinical social workers;
(12)
					 podiatrists;
(13)
					 chiropractors;
(14) occupational
					 therapists; and
(15) physical
					 therapists.
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 21.2431 - Required Analyses for Quantitative and Nonquantitative Parity; Alternative Tools

Current through Reg. 49, No. 28; July 12, 2024
(a) QTL and NQTL
					 templates.
(1) For purposes of this division,
					 "QTL template" is the template titled "Compliance Analysis for Quantitative
					 Parity" and its associated technical instructions, available on TDI's
					 website.
(2) For purposes of this
					 division, "NQTL template" is the template titled Compliance Analysis for
					 Nonquantitative Parity" and its associated technical instructions, available on
					 TDI's website.
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 21.2432 - Due Dates for Analyses

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Deadline for quantitative parity analyses. An issuer must complete the parity
					 analyses of its quantitative treatment limitations (QTLs) required by this
					 division for each existing plan not later than the 180th day after the
					 effective date of this subchapter.
(b) Phase-in for nonquantitative parity
					 analyses. The deadlines for completing the parity analyses of an issuer's
					 nonquantitative treatment limitations (NQTLs) will be phased in over three
					 years, in the following manner:
(1) Not later
					 than June 1, 2022, an issuer must complete its initial analysis of each of its
					 utilization review-related NQTLs, including:
(A) medical management standards limiting or
					 excluding benefits based on medical necessity or medical appropriateness, or
					 based on whether the treatment is experimental or investigative;
(B) refusal to pay for higher-cost therapies
					 until it can be shown that a lower-cost therapy is not effective (also known as
					 fail-first policies or step therapy protocols);
(C) exclusions based on failure to complete a
					 course of treatment;
(D)
					 preauthorization or ongoing authorization requirements; and
(E) concurrent review
					 standards.
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 21.2433 - Compliance Analysis for Quantitative Parity: General Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Template and instructions. Except as
					 provided in § 21.2431 of this title (relating to Required Analyses for
					 Quantitative and Nonquantitative Parity; Alternative Tools), an issuer must use
					 the QTL template and associated technical instructions to:
(1) provide the information required by
					 § 21.2434 of this title (relating to Quantitative Parity Analysis: Issuer
					 and Plan Information), § 21.2435 of this title (relating to Quantitative
					 Parity Analysis: Methodology for Determining Expected Payments), and §
					 21.2436 of this title (relating to Quantitative Parity Analysis: Covered
					 Benefits); and
(2) perform the
					 compliance analysis for quantitative parity required by § 21.2437 of this
					 title (relating to Quantitative Parity Analysis: "Substantially All" and
					 "Predominant" Tests).
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 21.2434 - Quantitative Parity Analysis: Issuer and Plan Information

Current through Reg. 49, No. 28; July 12, 2024
(a) Identifying issuer information. Within
					 each QTL template, in the worksheet titled "Issuer and Plan Information," an
					 issuer must provide the:
(1) issuer
					 name;
(2) NAIC number, or if none,
					 issuer license number;
(3) date the
					 analysis was completed (analysis completion date);
(4) contact name;
(5) phone number; and
(6) email address.
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 21.2435 - Quantitative Parity Analysis: Methodology for Determining Expected Payments

Current through Reg. 49, No. 28; July 12, 2024
(a) Expected payment methodology. Within each
					 QTL template, in the worksheet titled "Expected Payment Methodology," an issuer
					 must provide an explanation of the methodology that describes the underlying
					 data used to determine the total payments of each benefit in the quantitative
					 analyses, such as the steps, data, and assumptions used to calculate or project
					 expected payments. The description must demonstrate that:
(1) the quantitative analysis is based on the
					 total allowed amounts (not limited to the portion paid by the plan), projected
					 for the applicable plan year;
(2)
					 the quantitative analysis for each classification and subclassification, if
					 applicable, accounts for all expected payments for all covered medical/surgical
					 benefits under the plan or plan design; and
(3) a reasonable method was used to determine
					 the expected payment amount. An issuer must document the assumptions used in
					 choosing a data set and making projections.
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

Current through Reg. 49, No. 28; July 12, 2024
(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.
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 21.2437 - Quantitative Parity Analysis: "Substantially All" and "Predominant" Tests

Current through Reg. 49, No. 28; July 12, 2024
(a) Separate worksheet and analysis for each
					 classification and subclassification. Within the QTL template are separate
					 worksheets, named for each classification or subclassification (classification
					 worksheets) identified in § 21.2436(e) of this title (relating to
					 Quantitative Parity Analysis: Covered Benefits). If an issuer's plan design
					 applies a QTL or financial requirement to a MH/SUD benefit in a given
					 classification or subclassification, the issuer must document, in the
					 applicable classification worksheet, the following:
(1) in Column 1 of each classification
					 worksheet: the dollar amount or per member per month amount of all plan
					 payments expected to be paid under the plan for the plan year consistent with
					 §21.2408(c)(1)(C) - (E) of this title (relating to Parity Requirements
					 with Respect to Financial Requirements and Treatment Limitations);
(2) in Column 2 of each classification
					 worksheet: whether a copay applies and, if applicable, the copay
					 amount;
(3) in Column 3 of each
					 classification worksheet: whether a coinsurance applies and, if applicable, the
					 coinsurance percentage amount;
(4)
					 in Column 4 of each classification worksheet: whether a deductible applies and,
					 if applicable, the deductible amount;
(5) in Column 5 of each classification
					 worksheet: whether a session limit applies and, if applicable, the session
					 limit quantity; and
(6) in Column 6
					 of each classification worksheet: whether a day limit applies to each service
					 category and, if applicable, the day limit quantity.
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 21.2438 - Compliance Analysis for Nonquantitative Parity: General Instructions

Current through Reg. 49, No. 28; July 12, 2024
(a) Template and instructions. Except as
					 provided in § 21.2431 of this title (relating to Required Analyses for
					 Quantitative and Nonquantitative Parity; Alternative Tools), an issuer must use
					 the template and its associated technical instructions published on TDI's
					 website, titled "Compliance Analysis for Nonquantitative Parity" (NQTL
					 template), to perform the plan identification and compliance analyses for NQTL
					 parity required by:
(1)
												§ 21.2440 of
					 this title (relating to Nonquantitative Parity Analysis: Issuer and Plan
					 Information); and
(2)
												§
					 21.2441 of this title (relating to Four-Step Analysis of Nonquantitative
					 Treatment Limitations).
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 21.2440 - Nonquantitative Parity Analysis: Issuer and Plan Information

Current through Reg. 49, No. 28; July 12, 2024
(a) Identifying issuer information. Within
					 the NQTL template, in the worksheet titled "Issuer and Plan Information," an
					 issuer must provide the:
(1) issuer
					 name;
(2) NAIC number, or if none,
					 issuer license number;
(3) date the
					 analysis was completed (completion date);
(4) version control number;
(5) date of the most recent NQTL analysis
					 update (revision date);
(6) contact
					 name;
(7) phone number;
					 and
(8) email
					 address.
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 21.2441 - Four-Step Analysis of Nonquantitative Treatment Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Four-step analysis. An issuer must
					 complete the four-step analysis detailed in this section for each NQTL
					 contained in the plan documents for each plan. An issuer must report its NQTL
					 analyses separately for each applicable classification or subclassification,
					 using the classification worksheets as described in subsection (b) of this
					 section.
(b) Step 1. Within the
					 NQTL template, in the worksheet titled "NQTL Summary," an issuer must identify
					 each NQTL that applies to MH/SUD or medical/surgical benefits covered by the
					 plan, including, but not limited to, those identified in § 21.2439 of this
					 title (relating to Nonquantitative Treatment Limitations Generally).
(1) Within the NQTL Summary worksheet, an
					 issuer must identify, for each NQTL listed:
(A) whether the NQTL does or does not apply
					 to benefits categorized as:
(i)
					 medical/surgical benefits; and
(ii)
					 MH/SUD benefits; and
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 4 - AUTISM SPECTRUM DISORDER › Section 21.2451 - Applicability

Current through Reg. 49, No. 28; July 12, 2024
Applicability. This division applies only to health
						benefit plans that provide coverage for autism spectrum disorder as required by
						Insurance Code Chapter 1355, Subchapter A, concerning Group Health Benefit Plan
						Coverage for Certain Serious Mental Illnesses and Other
						Disorders.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter P - MENTAL HEALTH PARITY › Division 4 - AUTISM SPECTRUM DISORDER › Section 21.2452 - Coordination of Provisions in Insurance Code Chapter 1355, Concerning Benefits for Certain Mental Disorders

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Applicability. This section applies only to a health benefit plan that is
					 subject to both:
(1) Insurance Code Chapter
					 1355, Subchapter A, concerning Group Health Benefit Plan Coverage for Certain
					 Serious Mental Illnesses and Other Disorders; and
(2) Insurance Code Chapter 1355, Subchapter
					 F, concerning Coverage for Mental Health Conditions and Substance Use
					 Disorders.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Q - COMPLAINT RECORDS TO BE MAINTAINED › Section 21.2501 - Applicability and Purpose

Current through Reg. 49, No. 28; July 12, 2024
This subchapter applies to all insurers as defined in
					 §
										21.2502 of
					 this title (relating to Definitions). The purpose of this subchapter is to
					 prescribe the minimum information required to be maintained in the complaint
					 record of an insurer, to provide a recommended format for the maintenance of
					 such a record by insurers, and to require presentation of such information at
					 the time of examination of insurers or upon other request for complaint record
					 information by the department. Complaint record maintenance provisions of this
					 subchapter apply to all complaints of an insurer not specifically excepted by
					 this subchapter, including complaints relating to the claims settlement
					 practices of an insurer.
(1) This
				  subchapter does not apply to complaints received and maintained by Health
				  Maintenance Organizations. Insurance Code Chapter 843, Subchapter G, as
				  amended, as well as §
										11.205
				  of this title (relating to Additional Documents to be Available for Review),
				  expressly and specifically provide for complaint record maintenance by
				  HMOs.
(2) This subchapter does not
				  apply to the complaints received by an insurer in its capacity as a utilization
				  review agent. Complaint record maintenance and reporting for such complaints
				  are addressed in §
										19.1705
				  of this title (relating to General Standards of Utilization Review).
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Q - COMPLAINT RECORDS TO BE MAINTAINED › Section 21.2502 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words or phrases, as used in these sections,
					 shall have the meanings placed opposite them unless the explicit wording of a
					 section or part of a section shall otherwise direct.
(1) Complainant--A person making or having
				  made a complaint.
(2)
				  Complaint--Any written communication to an insurer, not solicited by such
				  insurer, concerning coverage offered or issued by such insurer in this state
				  and primarily expressing a grievance. For purposes of this subchapter, any
				  written communication to an insurer by the same person which relates to the
				  same claim, issue or question and requests or demands the same kind of relief
				  and which arises out of the same transaction or transactions is considered to
				  be part of the same complaint. A complaint is not a misunderstanding or a
				  problem of misinformation that is resolved promptly by clearing up the
				  misunderstanding and/or supplying the appropriate information to the
				  satisfaction of the person submitting the written communication, as
				  applicable.
(3) Complaint
				  record--An electronic or hard copy record maintained by an insurer on a
				  calendar-year basis and consisting of all complaints it has received during the
				  preceding three years or since the date of its most recent financial
				  examination, whichever time period is shorter.
(4) Insurer--Stock and mutual life, health,
				  accident, fire, casualty, fire and casualty, hail, storm, title, and mortgage
				  guarantee companies; mutual assessment companies; local mutual aid
				  associations; local mutual burial associations; statewide mutual assessment
				  companies; stipulated premium companies; fraternal benefit societies; group
				  hospital service organizations; county mutual insurance companies; Lloyds;
				  reciprocal or interinsurance exchanges; and farm mutual insurance
				  companies.
(5) Person--Any natural
				  or artificial entity, including but not limited to, an individual, an
				  association, or a partnership, trust or corporation.
(6) Written communication--Any communication
				  that is documented by publication or otherwise being written onto a medium
				  which is capable at the point of receipt of being viewed, stored, retrieved and
				  reproduced by the recipient insurer without any transcription. Such
				  communication expressly includes facsimile transmissions and electronic mail
				  transmissions.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Q - COMPLAINT RECORDS TO BE MAINTAINED › Section 21.2503 - Compliance Standard

Current through Reg. 49, No. 28; July 12, 2024
An insurer must maintain a complete record of all
					 complaints which it has received during the preceding three years or since the
					 date of its most recent financial examination by the commissioner of insurance,
					 whichever time period is shorter, in substantial compliance with the provisions
					 of this subchapter.
(1) For purposes
				  of this subchapter, "substantial compliance" shall mean that the record
				  maintained by the insurer must capture the prescribed minimum complaint
				  information items set out in this subchapter, and must be provided to the
				  department upon examination of the insurer or within prescribed statutory time
				  periods or other reasonable time following a request from the department for
				  such complaint information. Substantial compliance includes presenting such
				  information to the department so that, if requested, a complete record of all
				  complaints as set out in §
										21.2504
				  of this title (relating to Complaint Record; Required Elements; Explanation and
				  Instructions) is provided upon examination or pursuant to a request for such
				  complaint information by the department.
(2) Maintenance of a complaint record and
				  provision of such complaint information to the department under this subchapter
				  do not constitute a waiver of any exception to public disclosure provided by
				  law.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Q - COMPLAINT RECORDS TO BE MAINTAINED › Section 21.2504 - Complaint Record; Required Elements; Explanation and Instructions

Current through Reg. 49, No. 28; July 12, 2024
(a) Complaint record: general information.
				  The complaint record provided for in this subchapter shall be maintained by all
				  insurers. The complaint record is based on the Model Regulation for Complaint
				  Records to be Maintained adopted by the National Association of Insurance
				  Commissioners (NAIC), and incorporates the prescribed minimum information
				  required to be maintained in a complaint record complying with all maintenance
				  provisions of the NAIC Model regulation. The complaint record is intended and
				  recommended to be maintained as a single, comprehensive record. The complaint
				  record presented to the department at time of examination or in response to
				  department request must indicate the total number of complaints received for
				  the applicable time interval as set out in this subchapter.
(1) The complaint record may be maintained at
				  the option of the insurer in either an electronic format or a hard-copy
				  format.
(2) The format set out in
				  §
											21.2505 of
				  this title (relating to Complaint Record Form) is preferred and recommended for
				  both maintenance and presentation. Moreover, utilization of NAIC Complaint
				  Database System Standard Complaint Data Form classification coding conventions
				  for the classifications and categories set out in subsections (b)-(h) of this
				  section, as applicable, is preferred as a maintenance and presentation
				  option.
(3) If the complaint record
				  is maintained in a format other than the recommended form or as a decentralized
				  record, the insurer must nonetheless be capable of providing the department a
				  complete complaint record upon examination or other departmental request.
				  Subsections (b)-(i) of this section set out information items to be included in
				  the complaint record and refer to the recommended documentary format.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Q - COMPLAINT RECORDS TO BE MAINTAINED › Section 21.2505 - Complaint Record Form

Current through Reg. 49, No. 28; July 12, 2024
(a) Recommended
				  maintenance form. The recommended form for complaint record maintenance is
				  available on TDI's website at
www.tdi.texas.gov/forms
.
(b) Texas Department of Insurance Complaint
				  Record Form.
Attached
					 Graphic
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Q - COMPLAINT RECORDS TO BE MAINTAINED › Section 21.2506 - Maintenance Basis and Compilation Frequency of the Complaint Record

Current through Reg. 49, No. 28; July 12, 2024
The complaint record shall be maintained on a calendar-year
					 basis. All information items required to be maintained, including the number of
					 complaints by line of insurance, function, reasons, disposition, complaint
					 origin, and dates received and closed, shall be compiled not less frequently
					 than once a year.
Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter Q - COMPLAINT RECORDS TO BE MAINTAINED › Section 21.2507 - Effective Date

Current through Reg. 49, No. 28; July 12, 2024
Provisions of this subchapter addressing complaint record
					 maintenance and presentation apply to all complaints of an insurer received on
					 or after January 1, 1999.