(a) Expected payment methodology. Within each QTL template, in the worksheet titled "Expected Payment Methodology," an issuer must provide an explanation of the methodology that describes the underlying data used to determine the total payments of each benefit in the quantitative analyses, such as the steps, data, and assumptions used to calculate or project expected payments. The description must demonstrate that:
  (1) the quantitative analysis is based on the total allowed amounts (not limited to the portion paid by the plan), projected for the applicable plan year;
  (2) the quantitative analysis for each classification and subclassification, if applicable, accounts for all expected payments for all covered medical/surgical benefits under the plan or plan design; and
  (3) a reasonable method was used to determine the expected payment amount. An issuer must document the assumptions used in choosing a data set and making projections.
(b) Data sources. An issuer must clearly describe the following information, in addition to any other relevant information:
  (1) the specific plans or other sources of claims data used to determine the expected payment amounts for the analysis;
  (2) the time period of the claims data--for example, calendar years 2018 and 2019; and
  (3) what adjustments, if any, were made to the data or payment projections.
(c) Insufficient plan-level data. If data other than plan-level data was used for the analysis, an issuer must submit a separate actuarial certification addressing:
  (1) the sufficiency and credibility of plan-level data; and
  (2) why the substitute data set used for the analyses is reasonable and actuarially appropriate, including a description of any assumptions used in choosing the data and making projections.

Source Note: The provisions of this §21.2435 adopted to be effective September 7, 2021, 46 TexReg 5571