| (A) a projection based on claims data for the plan
or the plan design, if there is sufficient claims data for a reasonable
projection of future claims costs; or
(B) a projection based on appropriate and sufficient
data (such as data from other similarly structured plans with similar
demographics) to perform the analysis in compliance with applicable
Actuarial Standards of Practice set by the Actuarial Standards Board
if:
(i) there is not enough claims data;
(ii) the plan significantly changed its benefit package;
(iii) the plan experienced a significant workforce
change that would impact claims costs; or
(iv) the group health plan (or the plan design) is
new.
(32) Reported claims--Claims that are received by an
issuer in a year, regardless of the incurred date, the final decision
date, or a claim's pending status. For example, claims reported in
2020 could include claims incurred in 2019, claims with final decisions
made in the first few months of 2020, or claims awaiting a determination.
(33) Retrospective review--The process of reviewing
the medical necessity and reasonableness of health care that has been
provided to an enrollee.
(34) Small group market--Health benefit plans subject
to Insurance Code Chapter 1355, Subchapter F, that are sold to groups
that have at least two but no more than 50 members.
(35) Substance use disorder benefit--A benefit with
respect to an item, treatment, or service for a substance use disorder,
as defined under the terms of a health benefit plan and in accordance
with applicable federal and state law. Any disorder defined by the
plan as being or as not being a substance use disorder must be defined
to be consistent with generally recognized independent standards of
current medical practice (for example, the most current version of
the DSM, the most recent edition of the ICD, or state guidelines).
(36) Treatment limitations--This term includes limits
on benefits based on the frequency of treatment, number of visits,
days of coverage, days in a waiting period, or other similar limits
on the scope or duration of treatment. Treatment limitations include
both quantitative treatment limitations (QTLs), which are expressed
numerically (such as 50 outpatient visits per year), and NQTLs, which
otherwise limit the scope or duration of benefits for treatment under
a plan. (An illustrative list of NQTLs is provided in §21.2409(b)
of this title (relating to Nonquantitative Treatment Limitations).)
A permanent exclusion of all benefits for a particular condition or
disorder, however, is not a treatment limitation for purposes of this
definition.
(37) Utilization review--A system for prospective,
concurrent, or retrospective review of the medical necessity or appropriateness
of health care services or benefits and a system for prospective,
concurrent, or retrospective review to determine the experimental
or investigational nature of health care services or benefits. The
term does not include a review in response to an elective request
for clarification of coverage.
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