SECTION 21.2437. Quantitative Parity Analysis: "Substantially All" and "Predominant" Tests

(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.

(b) "Substantially all" test. Consistent with §21.2408(c)(1)(A) of this title, an issuer must perform the following calculations separately in each classification worksheet to determine whether a QTL or financial requirement that applies to MH/SUD benefits also applies to substantially all medical/surgical benefits.

(1) To calculate the aggregate total of expected plan payments for medical/surgical benefits in the classification worksheet, add the dollar amounts listed in every row of Column 1.

(2) To determine whether a copay applies to substantially all medical/surgical benefits in the classification worksheet:

(A) for every row in Column 2 of the worksheet with a copay amount listed greater than $0, add the expected plan payment amounts for the benefit listed in Column 1 of that row; and

(B) divide the amount in subsection (b)(2)(A) of this section by the aggregate total calculated under subsection (b)(1) of this section.

(3) To determine whether a coinsurance applies to substantially all medical/surgical benefits in the classification worksheet:

(A) for every row in Column 3 of the worksheet with an enrollee coinsurance amount listed greater than $0, add the expected plan payment amounts for the benefit listed in Column 1 of that row; and

(B) divide the amount addressed in subsection (b)(3)(A) of this section by the aggregate total calculated under subsection (b)(1) of this section.

(4) To determine whether a deductible applies to substantially all medical/surgical benefits in the classification worksheet:

(A) for every row in Column 4 of the worksheet with a deductible amount listed greater than $0, add the expected plan payment amounts for the benefit listed in Column 1 of that row; and

(B) divide the amount addressed in subsection (b)(4)(A) of this section by the aggregate total calculated under subsection (b)(1) of this section.

(5) To determine whether a session limit applies to substantially all medical/surgical benefits in the classification worksheet:

(A) for every row in Column 5 of the worksheet with a session limit listed that is less than unlimited, add the expected plan payment amounts for the benefit category listed in Column 1 of that row; and

(B) divide the amount addressed in subsection (b)(5)(A) of this section by the aggregate total calculated under subsection (b)(1) of this section.

(6) To determine whether a day limit applies to substantially all medical/surgical benefits in the classification worksheet:

(A) for every row in Column 6 of the worksheet with a day limit listed that is less than unlimited, add the expected plan payment amounts for the benefit listed in Column 1 of that row; and

(B) divide the amount addressed in subsection (b)(6)(A) of this section by the aggregate total calculated under subsection (b)(1) of this section.

(7) If the amount calculated under any of the paragraphs in subsections (b)(2) - (b)(6) of this section is less than two-thirds on any of the classification worksheets, the financial requirement or quantitative treatment limitation in that paragraph fails the "substantially all" test under §21.2408(c)(1)(A) of this title and cannot be applied to a MH/SUD benefit.

(c) "Predominant" test. Consistent with §21.2408(c)(1)(B) of this title, the issuer must separately perform the following calculations in each classification worksheet, as applicable, to determine whether the level of a type of quantitative treatment limitation or financial requirement that satisfied the "substantially all" test in subsection (b) of this section is no less favorable than the predominant quantitative treatment limitation or financial requirement that applies to medical/surgical benefits.

(1) Calculate the aggregate total of expected plan payments for medical/surgical benefits within each classification or subclassification that is subject to a particular type of financial requirement or quantitative treatment limitation. Separately, in Columns 2 through 6 of the classification worksheet, for every row with an amount listed, add the expected claim dollar amounts from Column 1 of the worksheet for the benefit listed in that row.

(2) To determine whether the level of a financial requirement or quantitative treatment limitation applied to MH/SUD is not less favorable than the predominant financial requirement or quantitative treatment limitation applied to medical/surgical benefits, follow the instructions in the following subparagraphs for each financial requirement and quantitative treatment limitation identified in Columns 2 through 4 of each classification worksheet.

(A) Rank each level of each type of financial requirement and quantitative treatment limitation from highest to lowest.

(B) For each level of each type of financial requirement and quantitative treatment limitation identified in Columns 2 through 4 of the classification worksheet, add the expected plan payments identified in Column 1 of the worksheet for each benefit to which the level of financial requirement or quantitative treatment limitation applies.

(C) Divide each amount calculated under subsection (c)(2)(B) of this section by the aggregate total addressed in subsection (c)(1) of this section.

(D) Add the amounts calculated under subsection (c)(2)(C) of this section for each level of each type of financial requirement and quantitative treatment limitation identified in Columns 2 through 4 of the classification worksheet, from highest to lowest, until the aggregate total exceeds 50%.

(E) In each of the classification worksheets, the least restrictive level of each type of financial requirement or quantitative treatment limitation calculated under subsection (c)(2)(D) of this section to exceed 50% is the predominant level and the least restrictive level that can be applied to MH/SUD benefits. For example:

(i) for copays, coinsurance, and deductibles, the predominant level is the highest amount that can be applied to MH/SUD benefits; and

(ii) for day limits and session limits, the predominant level is the lowest level of day or session limits that can be applied to MH/SUD benefits.

Source Note: The provisions of this §21.2437 adopted to be effective September 7, 2021, 46 TexReg 5571