This section details application of the parity requirements
under this subchapter with respect to aggregate lifetime and annual
dollar limits that may be permitted by state or federal law.
(1) General parity requirement. A health benefit plan
that provides both medical/surgical benefits and MH/SUD benefits must
comply with paragraph (2), (3), or (5) of this section, as applicable.
(2) Plan with no limit or limits on less than one-third
of all medical/surgical benefits. If a health benefit plan does not
include an aggregate lifetime or annual dollar limit on any medical/surgical
benefits or includes an aggregate lifetime or dollar limit that applies
to less than one-third of all medical/surgical benefits, it may not
impose an aggregate lifetime or annual dollar limit, respectively,
on mental health or substance use disorder benefits.
(3) Plan with a limit on at least two-thirds of all
medical/surgical benefits. If a health benefit plan includes an aggregate
lifetime or annual dollar limit on at least two-thirds of all medical/surgical
benefits, it must either:
(A) apply the aggregate lifetime or annual dollar limit
both to the medical/surgical benefits to which the limit would otherwise
apply and to MH/SUD benefits in a manner that does not distinguish
between the medical/surgical benefits and MH/SUD benefits; or
(B) not include an aggregate lifetime or annual dollar
limit on mental health or substance use disorder benefits that is
less than the aggregate lifetime or annual dollar limit, respectively,
on medical/surgical benefits. (Some cumulative financial requirements
and cumulative quantitative treatment limitations other than aggregate
lifetime or annual dollar limits are prohibited in §21.2408 of
this title (relating to Parity Requirements with Respect to Financial
Requirements and Treatment Limitations).)
(4) Determining one-third and two-thirds of all medical/surgical
benefits. For purposes of this section, the determination of whether
the portion of medical/surgical benefits subject to an aggregate lifetime
or annual dollar limit represents one-third or two-thirds of all medical/surgical
benefits is based on the dollar amount of all plan payments for medical/surgical
benefits expected to be paid under the plan for the plan year (or
for the portion of the plan year after a change in plan benefits that
affects the applicability of the aggregate lifetime or annual dollar
limits). Any reasonable method may be used to determine whether the
dollar amount expected to be paid under the plan will constitute one-third
or two-thirds of the dollar amount of all plan payments for medical/surgical
benefits.
(5) Plan not described in paragraph (2) or (3) of this
section.
(A) In general. A health benefit plan that is not described
in paragraph (2) or (3) of this section with respect to aggregate
lifetime or annual dollar limits on medical/surgical benefits, must
either:
(i) impose no aggregate lifetime or annual dollar limit,
as appropriate, on mental health or substance use disorder benefits;
or
(ii) impose an aggregate lifetime or annual dollar
limit on mental health or substance use disorder benefits that is
no less than an average limit calculated for medical/surgical benefits
in the following manner. The average limit is calculated by taking
into account the weighted average of the aggregate lifetime or annual
dollar limits, as appropriate, that are applicable to the categories
of medical/surgical benefits. Limits based on delivery systems, such
as inpatient/outpatient treatment or normal treatment of common, low-cost
conditions (such as treatment of normal births), do not constitute
categories for purposes of this clause. In addition, for purposes
of determining weighted averages, any benefits that are not within
a category that is subject to a separately designated dollar limit
under the plan are taken into account as a single separate category
by using an estimate of the upper limit on the dollar amount that
a plan may reasonably be expected to incur with respect to such benefits,
taking into account any other applicable restrictions under the plan.
(B) Weighting. For purposes of this paragraph, the
weighting applicable to any category of medical/surgical benefits
is determined in the manner set forth in paragraph (4) of this section
for determining one-third or two-thirds of all medical/surgical benefits.
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