Aggregate Lifetime and Annual Dollar Limits
Texas Health and Human Services or the managed care organization must identify and analyze aggregate lifetime limits and annual dollar limits for parity compliance in each benefit package if these types of limitations apply to mental health and substance use disorder benefits.
An aggregate lifetime dollar limit is the maximum amount that will be paid by an MCO. An annual dollar limit is a limitation on what an MCO will pay in a 12-month period. For aggregate lifetime and annual dollar limits, HHS or the MCO must identify and analyze limitations using a cost-based test. States and MCOs cannot apply aggregate lifetime or annual dollar limits to mental health and substance use disorder benefits if:
- There are no aggregate lifetime limits or no annual dollar limits on any medical and surgical (MS) services.
- The aggregate lifetime or annual dollar limits do not apply to at least one-third of expected payments for all medical and surgical benefits in a year.
Financial Requirements and Quantitative Treatment Limitations
Financial requirements for beneficiaries include deductibles, coinsurance, copayments and out-of-pocket maximums. Quantitative treatment limitations indicates numerical limitations on services.
The state or MCO must determine whether the financial requirements and QTLs between MS and mental health/substance use disorder (MHSUD) services are comparable using a two-part test. A financial requirement or QTL that applies to mental health and substance use disorders within a classification may not be more restrictive than the predominant financial requirement or QTL that applies to substantially all medical surgical benefits in that classification.
Parity in Non-Quantitative Treatment Limitations
MCOs cannot apply non-quantitative treatment limitations unless — under the policies and procedures of the MCO, as written and in operation — any processes, strategies, evidentiary standards or other factors used in applying NQTLs to MHSUD benefits are comparable to and applied no more stringently than those applied to NQTLs to MS benefits within the same classification.