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As required by Mental Health Parity and Addiction Equity Act, when the managed care organization (MCO) does not provide the full scope of services, the state must review the mental health and substance use disorder (MHSUD), and medical and surgical (MS) benefits provided through the MCO and fee-for-service for parity compliance. Though Texas Medicaid is predominantly managed care, the MCO does not provide the full scope of services, and some beneficiaries receive a few services through the fee-for-service delivery mechanism. In this case, HHS — not the MCOs — must assess Medicaid and CHIP programs for compliance with federal parity rules.
In 2017, HHS analyzed the quantitative treatment limitations of its state plan Medicaid benefits for compliance and provided direct oversight of each MCO’s analysis for non-quantitative treatment limitations.
Benefit Packages
For parity compliance, the state identified three benefit packages:
- Medicaid for adults (age 21 and older)
- Medicaid for children (birth through age 20)
- Children’s Health Insurance Program (CHIP)
Managed Care Organization | Benefit Package | ||
|---|---|---|---|
Children | Adult | CHIP | |
Aetna | Yes | Yes | Yes |
Amerigroup Texas | Yes | Yes | Yes |
Blue Cross Blue Shield of Texas | Yes | Yes | Yes |
Children’s Medical Center Health Plan | Yes | No | No |
Christus Health Plan | Yes | Yes | Yes |
Cigna-Health Spring | No | Yes | No |
Community Health Choice | Yes | Yes | Yes |
Community First Health Plan | Yes | Yes | Yes |
Cook Children’s Health Plan | Yes | Yes | Yes |
Driscoll Children’s Health Plan | Yes | Yes | Yes |
El Paso First Health Plans | Yes | Yes | Yes |
First Care | Yes | Yes | Yes |
Molina Healthcare of Texas | Yes | Yes | Yes |
Parkland Community Health Plan | Yes | Yes | Yes |
Scott and White Health Plan | Yes | Yes | No |
Dell Children’s Hospital Plan | Yes | Yes | Yes |
Superior Health Plan | Yes | Yes | Yes |
Texas Children’s Health Plan | Yes | Yes | Yes |
United Healthcare Community Plan | Yes | Yes | Yes |
Defining Medical and Surgical or Mental Health and Substance Use Disorders
HHS used the International Classification of Diseases, Tenth Revision (ICD-10), as the generally recognized standard to make determinations about which benefits are used to treat mental health and substance use disorders. All disorders listed in the F chapter of the ICD-10 with the exception of mental disorders due to known physiological conditions (F01-F09), nicotine dependence (F17) and IQ-related disabilities and disorders (F70-F89) were designated as mental health and substance use disorders. These exceptions and all other disorders in the ICD-10 were classified as medical and surgical conditions.
HHS determined that benefits used to treat a mental health or substance use disorder were considered mental health and substance use disorder benefits; benefits used to treat medical and surgical disorders were considered medical and surgical benefits. If a benefit can be used to treat both mental health and substance use disorder and medical and surgical disorders, then the benefit was listed in both categories. HHS classified each benefit into the inpatient, outpatient or emergency services classification.
HHS used the American Hospital Formulary Service Codes, a nationally recognized standardized system of classification for prescription drugs, to list benefits in the pharmacy classification under the mental health and substance use disorder, medical and surgical disorder, or both categories.
Defining Classifications
To determine which benefits belonged in each classification, HHS considered how the benefit would be claimed and the setting(s) in which the benefit would be delivered. Some benefits, because they can be delivered in multiple settings, were placed in more than one classification. Drugs or drug classes that are on the Texas Medicaid and CHIP Formulary were placed in the pharmacy classification.