| (a) Clarification of terms.
(1) Classification of benefits. When reference is made
in this subchapter to a classification of benefits, the term "classification"
means a classification as described in subsection (b)(2) of this section.
(2) Type of financial requirement or treatment limitation.
When reference is made in this subchapter to a type of financial requirement
or treatment limitation, the reference to type means its nature. Different
types of financial requirements include deductibles, copayments, coinsurance,
and out-of-pocket maximums. Different types of quantitative treatment
limitations include annual, episode, and lifetime day and visit limits.
An illustrative list of nonquantitative treatment limitations is provided
in §21.2409(b) of this title (relating to Nonquantitative Treatment
Limitations).
(3) Level of a type of financial requirement or treatment
limitation. When reference is made in this subchapter to a level of
a type of financial requirement or treatment limitation, "level" refers
to the magnitude of the type of financial requirement or treatment
limitation. For example, different levels of coinsurance include 20%
and 30%, different levels of a copayment include $15 and $20, different
levels of a deductible include $250 and $500, and different levels
of an episode limit include 21 inpatient days per episode and 30 inpatient
days per episode.
(4) Coverage unit. When reference is made in this subchapter
to a coverage unit, "coverage unit" refers to the way in which a health
benefit plan groups individuals for purposes of determining benefits,
or premiums or contributions. For example, different coverage units
include self-only, family, and employee-plus-spouse.
(b) General parity requirement.
(1) General requirement. A health benefit plan that
provides both medical/surgical benefits and mental health or substance
use disorder benefits may not apply any financial requirement or treatment
limitation to mental health or substance use disorder benefits in
any classification that is more restrictive than the predominant financial
requirement or treatment limitation of that type applied to substantially
all medical/surgical benefits in the same classification. Whether
a financial requirement or treatment limitation is a predominant financial
requirement or treatment limitation that applies to substantially
all medical/surgical benefits in a classification is determined separately
for each type of financial requirement or treatment limitation. The
application of the requirements of this subsection to financial requirements
and quantitative treatment limitations is addressed in subsection
(c) of this section; the application of the requirements of this subsection
to nonquantitative treatment limitations is addressed in §21.2409
of this title.
(2) Classifications of benefits used for applying requirements.
(A) In general. If a health benefit plan provides mental
health or substance use disorder benefits in any classification of
benefits described in this subparagraph, mental health or substance
use disorder benefits must be provided in every classification in
which medical/surgical benefits are provided. In determining the classification
in which a particular benefit belongs, a health benefit plan must
apply the same standards to medical/surgical benefits and to mental
health or substance use disorder benefits. To the extent that a health
benefit plan provides benefits in a classification and imposes any
separate financial requirement or treatment limitation (or separate
level of a financial requirement or treatment limitation) for benefits
in the classification, the requirements of this subsection apply separately
with respect to that classification for all financial requirements
or treatment limitations (illustrated in examples in paragraph (2)(C)
of this subsection). The following classifications of benefits are
the only classifications used in applying the requirements of this
subsection:
(i) An "inpatient, in-network" classification is for
benefits furnished on an inpatient basis and within a network of providers
established or recognized under a health benefit plan. Special requirements
for plans with multiple network tiers are addressed in subsection
(c)(3) of this section.
(ii) An "inpatient, out-of-network" classification
is for benefits furnished on an inpatient basis and outside any network
of providers established or recognized under a health benefit plan.
This classification includes inpatient benefits under a health benefit
plan that has no network of providers.
(iii) An "outpatient, in-network" classification is
for benefits furnished on an outpatient basis and within a network
of providers established or recognized under a health benefit plan.
Special requirements for office visits and plans with multiple network
tiers are addressed in subsection (c)(3) of this section.
(iv) An "outpatient, out-of-network" classification
is for benefits furnished on an outpatient basis and outside any network
of providers established or recognized under a health benefit plan.
This classification includes outpatient benefits under a health benefit
plan that has no network of providers. Special requirements for office
visits are addressed in subsection (c)(3) of this section.
(v) An "emergency care" classification is for benefits
for emergency care.
(vi) A "prescription drug" classification is for benefits
for prescription drugs. See special requirements for multi-tiered
prescription drug benefits in subsection (c)(3) of this section.
(B) Application to out-of-network providers. Application
to out-of-network providers is addressed in subparagraph (A) of this
paragraph, under which a health benefit plan that provides mental
health or substance use disorder benefits in any classification of
benefits must provide mental health or substance use disorder benefits
in every classification in which medical/surgical benefits are provided,
including out-of-network classifications.
(C) Examples. The requirements of this paragraph are
illustrated by examples provided in the figure §21.2408(b)(2)(C).
In each example, the health benefit plan is subject to the requirements
of this section and provides both medical/surgical benefits and mental
health and substance use disorder benefits.
Attached Graphic
(c) Financial requirements and quantitative treatment
limitations.
(1) Determining "substantially all" and "predominant."
(A) Substantially all. For purposes of this section,
a type of financial requirement or quantitative treatment limitation
is considered to apply to substantially all medical/surgical benefits
in a classification of benefits if it applies to at least two-thirds
of all medical/surgical benefits in that classification. (For this
purpose, benefits expressed as subject to a zero level of a type of
financial requirement are treated as benefits not subject to that
type of financial requirement, and benefits expressed as subject to
a quantitative treatment limitation that is unlimited are treated
as benefits not subject to that type of quantitative treatment limitation.)
If a type of financial requirement or quantitative treatment limitation
does not apply to at least two-thirds of all medical/surgical benefits
in a classification, then that type cannot be applied to mental health
or substance use disorder benefits in that classification.
(B) Predominant.
(i) If a type of financial requirement or quantitative
treatment limitation applies to at least two-thirds of all medical/surgical
benefits in a classification as determined under subparagraph (A)
of this paragraph, the level of the financial requirement or quantitative
treatment limitation that is considered the predominant level of that
type in a classification of benefits is the level that applies to
more than one-half of medical/surgical benefits in that classification
subject to the financial requirement or quantitative treatment limitation.
(ii) If, with respect to a type of financial requirement
or quantitative treatment limitation that applies to at least two-thirds
of all medical/surgical benefits in a classification, there is no
single level that applies to more than one-half of medical/surgical
benefits in the classification subject to the financial requirement
or quantitative treatment limitation, the plan may combine levels
until the combination of levels applies to more than one-half of medical/surgical
benefits subject to the financial requirement or quantitative treatment
limitation in the classification. The least restrictive level within
the combination is considered the predominant level of that type in
the classification. (For this purpose, a plan may combine the most
restrictive levels first, with each less restrictive level added to
the combination until the combination applies to more than one-half
of the benefits subject to the financial requirement or treatment
limitation.)
(C) Portion based on plan payments. For purposes of
this section, the determination of the portion of medical/surgical
benefits in a classification of benefits subject to a financial requirement
or quantitative treatment limitation (or subject to any level of a
financial requirement or quantitative treatment limitation) is based
on the dollar amount of all plan payments for medical/surgical benefits
in the classification expected to be paid under the plan for the plan
year (for the portion of the plan year after a change in plan benefits
that affects the applicability of the financial requirement or quantitative
treatment limitation).
(D) Clarifications for certain threshold requirements.
For any deductible, the dollar amount of plan payments includes all
plan payments with respect to claims that would be subject to the
deductible if it had not been satisfied. For any out-of-pocket maximum,
the dollar amount of plan payments includes all plan payments associated
with out-of-pocket payments that are taken into account toward the
out-of-pocket maximum, as well as all plan payments associated with
out-of-pocket payments that would have been made toward the out-of-pocket
maximum if it had not been satisfied.
(E) Determining the dollar amount of plan payments.
Subject to subparagraph (D) of this paragraph, any reasonable method
may be used to determine the dollar amount expected to be paid under
a plan for medical/surgical benefits subject to a financial requirement
or quantitative treatment limitation (or subject to any level of a
financial requirement or quantitative treatment limitation).
(2) Application to different coverage units. If a health
benefit plan applies different levels of a financial requirement or
quantitative treatment limitation to different coverage units in a
classification of medical/surgical benefits, the predominant level
that applies to substantially all medical/surgical benefits in the
classification is determined separately for each coverage unit.
(3) Special requirements.
(A) Multi-tiered prescription drug benefits. If a health
benefit plan applies different levels of financial requirements to
different tiers of prescription drug benefits based on reasonable
factors determined in accordance with the requirements in §21.2409(a)
of this title and without regard to whether a drug is generally prescribed
with respect to medical/surgical benefits or with respect to mental
health or substance use disorder benefits, the health benefit plan
satisfies the parity requirements of this section with respect to
prescription drug benefits. Reasonable factors include cost, efficacy,
generic versus brand name, and mail order versus pharmacy pick-up.
(B) Multiple network tiers. If a health benefit plan
provides benefits through multiple tiers of in-network providers (such
as an in-network tier of preferred providers with more generous cost-sharing
to participants than a separate in-network tier of participating providers),
the plan may divide its benefits furnished on an in-network basis
into subclassifications that reflect network tiers, if the tiering
is based on reasonable factors determined in accordance with the requirements
in §21.2409(a) of this title (such as quality, performance, and
market standards) and without regard to whether a provider provides
services with respect to medical/surgical benefits or mental health
or substance use disorder benefits. After the subclassifications are
established, the issuer may not impose any financial requirement or
treatment limitation on mental health or substance use disorder benefits
in any subclassification that is more restrictive than the predominant
financial requirement or treatment limitation that applies to substantially
all medical/surgical benefits in the subclassification using the methodology
in subsection (c)(1) of this section.
(C) Subclassifications permitted for office visits,
separate from other outpatient services. For purposes of applying
the financial requirement and treatment limitation requirements of
this section, a plan may divide its benefits furnished on an outpatient
basis into the two subclassifications described in this subparagraph.
After the subclassifications are established, the plan may not impose
any financial requirement or quantitative treatment limitation on
mental health or substance use disorder benefits in any subclassification
that is more restrictive than the predominant financial requirement
or quantitative treatment limitation that applies to substantially
all medical/surgical benefits in the subclassification using the methodology
in paragraph (1) of this subsection. Subclassifications other than
these special requirements, such as separate subclassifications for
generalists and specialists, are not permitted. The two subclassifications
permitted under this subparagraph are:
(i) office visits (such as physician visits), and
Cont'd... |
