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This page lists some of the action toward parity compliance undertaken by Texas regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org

Action in the Regulatory Arena

8/2017

Primary Focus: Mandated Benefit: Provider
Agency: Texas Department of Insurance
Title/Description: Basic Health Care Services and Mandatory Benefit Standards: Group, Individual, and Conversion Agreements
Citation: 28 Tex. Admin. Code § 11.508 per 42 TEXREG 2169
Summary: Each evidence of coverage providing basic health care services must provide coverage for outpatient mental health services complying with the mental health parity requirements in Chapter 21, Subchapter P, of this title (relating to Mental Health Parity).
Effective Date: August 1, 2017
Notes: N/A

Primary Focus: Mandated Benefit: Provider
Agency: Texas Department of Insurance
Title/Description: Minimum Standards—Mental Health and Chemical Dependency Services and Benefits
Citation: 28 Tex. Admin. Code § 11.2405 per 42 TEXREG 2169
Summary: Each limited service HMO providing coverage for mental health and chemical dependency services and benefits must comply with Chapter 21, Subchapter P, of this title (relating to Mental Health Parity) and provide primary mental health and chemical dependency services and benefits.
Effective Date: August 1, 2017
Notes: N/A

2014

The Texas Department of Insurance (TDI) released a chart (pdf | Get Adobe® Reader®) that shows the benefits that must be provided by health plans in Texas. The document shows which mental health and substance use disorder benefits must be offered by individual, small employer, and large employer plans (pages 2, 4, and 5). It clearly demonstrates that all plans must offer mental health benefits in parity with physical health benefits (page 5).

3/2011

Primary Focus: Mandated Benefit: Provider
Agency: Texas Department of Insurance
Title/Description: Small Employer Health Plan Parity Requirements
Citation: 28 Tex. Admin. Code § 21.2404 per 36 TEXREG 1291
Summary: Unless exempted by this subsection, an issuer of a group health plan to a small employer must offer coverage or serious mental illness as described in § 1355.004. The employer may reject the coverage, but if the employer accepts the coverage, such coverage must meet the requirements of § 1355.004.
Effective Date: March 2, 2011
Notes: N/A

1/1999

Primary Focus: Mandated Benefit: Provider
Agency: Texas Department of Insurance
Title/Description: Large Employer Health Plan Parity Requirements
Citation: 28 Tex. Admin. Code § 21.2403 per 24 TEXREG 393
Summary: Coverage that provides both medical/surgical benefits and mental health or substance use disorder benefits must apply substantially the same following limits to mental health benefits as it does to medical/surgical benefits:

(1)  Aggregate lifetime limit or an annual limit;

(2)  Financial requirements; and

(3)  Treatment limitations

Separate cost-sharing requirements or separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits are prohibited.
Effective Date: January 31, 1999
Notes: N/A

2008

The Texas Department of Insurance (TDI) issued a bulletin notifying constituents that the Texas Attorney General issued an opinion finding that group health plans in Texas are required to provide the same number of outpatient visits for serious mental illness as they do for physical illness. In the bulletin, TDI stated that they planned to conduct reviews of forms of carriers on file for parity compliance. The bulletin also noted that TDI would issue regulations to implement the Federal Parity Law, which it did in 2011 (see above).

Texas Parity Law

There are 2 sections of the state insurance law relevant to parity. There is one section of the law that addresses mental health and autism coverage, and another that addresses substance use disorders.

Because most of the autism requirements are in a separate subsection of the section on mental health and autism coverage, autism coverage will be summarized in a separate section of this page below.

Mental Health Section

This section applies to large employer fully-insured plans, small employer fully-insured plans, and local government plans. However, the coverage described below is optional for small employer fully-insured plans. Also, there is a separate subsection that applies to local government plans that is very brief (summarized below).

This section only applies coverage to the following conditions, defined in this section as “serious mental illness”:

  1. Bipolar disorders (hypomanic, manic, depressive, and mixed)
  2. Depression in childhood and adolescence
  3. Major depressive disorders (single episode or recurrent)
  4. Obsessive-compulsive disorders
  5. Paranoid and other psychotic disorders
  6. Schizo-affective disorders (bipolar or depressive)
  7. Schizophrenia

This section specifies that at least 45 inpatient days and 60 outpatient visits are required of plans affected by the law and states that plans “must include the same amount limitations, deductibles , copayments , and coinsurance factors for serious mental illness as the plan includes for physical illness.” It also states that plans “must provide coverage for an outpatient visit under the same terms as the coverage the issuer provides for an outpatient visit for the treatment of physical illness.”

This section also forbids any lifetime limitations within a plan for inpatient days and outpatient visits.

This section specifies that plans offering coverage in a hospital for a child or adolescent with a “mental or emotional illness or disorder” must provide coverage for the child in a “residential treatment center for children and adolescents or a crisis stabilization unit that is at least as favorable as the coverage the plan provides for treatment of mental or emotional illness or disorder in a hospital.” It also specifies that each two days of treatment in a residential treatment center or crisis stabilization unit are equivalent to one day of coverage for treatment in a hospital.

This section also has specific language addressing partial hospitalization. It specifies that plans that offer inpatient coverage must also provide coverage for “psychiatric day treatment.” It also specifies that each day of coverage for psychiatric day treatment is equivalent to one-half day of coverage for inpatient or hospital care.

This section explicitly allows plans to use managed care.

This section also has a small subsection that mandates that local governments may not provide coverage for serious mental illness that is that is “less extensive than the coverage provided for any other physical illness.”

Autism

The subsection within the mental health coverage section requires individual plans, small employer fully-insured plans, and large employer fully-insured plans to provide autism screening at 18 and 24 months. The subsection pertaining to autism also lists a number of “generally recognized services” for autism treatment:

  1. Evaluation and assessment services
  2. Applied behavior analysis
  3. Behavior training and behavior management
  4. Speech therapy
  5. Occupational therapy
  6. Physical therapy
  7. Medications or nutritional supplements used to address symptoms of autism spectrum disorder

This subsection defines autism spectrum disorder as “a neurological disorder that includes autism, Asperger’s syndrome, or Pervasive Developmental Disorder–Not Otherwise Specified.”

Deductibles, copayments, and coinsurance must be equivalent to those in place for other medical services. Plans are not required to pay more than $36,000 in a year for applied behavior analysis for children age 10 and older.

Substance Use Disorder Section

This section requires that treatment for chemical dependency is covered that is not “less favorable” that coverage for other medical care. It also specifies that durational limits, dollar limits, deductibles, and coinsurance must be the same as treatment coverage for other care. However, there is a significant caveat that a plan is only required to cover three separate treatment series during the lifetime of the plan for each enrollee.

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Texas Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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