|(a) General information. Within each QTL template,
in the worksheet titled "Covered Benefits," an issuer must identify:
(1) whether outpatient benefits are subclassified into
"office visit" and "other;"
(2) whether the plan or plan design has a tiered network;
(3) if the plan or plan design has a tiered network,
the number of tiers.
(b) List of covered benefits. In the worksheet titled
"Covered Benefits," an issuer must list each benefit covered by the
plan or plan design, including all benefits listed in the schedule
of benefits and the policy, certificate, evidence of coverage, or
contract of insurance. Covered benefits must be repeated as needed
to list each benefit on separate lines, based on:
(2) types and levels of applicable financial requirements
and QTLs; and
(3) classification or subclassification, as applicable.
(c) Combining covered benefits. Covered benefits that
have the same QTLs may be combined for the purposes of the QTL analysis;
(d) Examples. The examples in this subsection illustrate
the requirements of subsections (b) and (c) of this section.
(1) Example 1. If a plan or plan design covers the
first office visit with $0 cost sharing, and subsequent office visits
are subject to coinsurance, then each level of cost sharing must be
listed on a separate line.
(2) Example 2. If a plan or plan design covers occupational
therapy for both medical/surgical and MH/SUD diagnoses, then occupational
therapy must be listed on separate lines for each.
(3) Example 3. If a plan or plan design covers physical
therapy, occupational therapy, and speech therapy subject to identical
QTLs, then the covered benefits may be combined in a single line.
(4) Example 4. If a plan or plan design applies identical
types and levels of QTLs to all in-network medical/surgical and MH/SUD
covered benefits, then all in-network medical/surgical covered benefits
may be combined in a single line and all in-network MH/SUD covered
benefits may be combined in a single line, for a total of two lines
of covered benefits in each classification worksheet.
(e) Categorization, classification, and subclassification
of covered benefits. For each covered benefit, the issuer must:
(1) categorize the covered benefit, consistent with
the definitions of "medical/surgical benefit," "mental health benefit,"
and "substance use disorder benefit" in §21.2406 of this title
(relating to Definitions), as medical/surgical or MH/SUD;
(2) classify the covered benefit consistent with §21.2408(b)(2)(A)(i)
- (vi) of this title (relating to Parity Requirements with Respect
to Financial Requirements and Treatment Limitations) as:
(A) inpatient, in-network;
(B) inpatient, out-of-network;
(C) outpatient, in-network;
(D) outpatient, out-of-network; and
(E) emergency care;
(3) if the issuer uses multiple network tiers, add
separate subclassifications for in-network classifications, consistent
with §21.2408(c)(3)(B) of this title; and
(4) if applicable to outpatient benefits, subclassify
the covered benefit, consistent with §21.2408(c)(3)(C) of this
(A) outpatient, in-network including, if applicable,
separate identification of:
(i) outpatient in-network office visits; and
(ii) all other outpatient in-network benefits; and
(B) outpatient, out-of-network, including, if applicable,
separate identification of:
(i) outpatient out-of-network office visits; and
(ii) all other outpatient out-of-network benefits.
(f) Methodology for categorizing covered benefits.
Within the QTL template, in the worksheet titled "Categorization Methodology,"
an issuer must provide an explanation of the methodology used to categorize
a covered benefit as a mental health benefit, medical/surgical benefit,
or substance use disorder benefit. If a plan defines a condition as
a mental health condition, substance use disorder, or medical or surgical
condition, it must categorize benefits for those conditions in the
same way for purposes of this rule. For example, if a plan defines
unspecified dementia as a mental health condition, it must categorize
benefits for unspecified dementia as mental health benefits. An issuer
must apply the same categorization for both the QTL and NQTL analyses.
(g) Methodology for classifying and subclassifying
covered benefits. Within the QTL template, in the worksheet titled
"Classification Methodology," an issuer must provide an explanation
of the methodology used to classify and subclassify covered benefits,
consistent with §21.2408(b)(2) and (c)(3) of this title. In determining
the classification in which a particular benefit belongs, an issuer
must apply the same standards to medical/surgical benefits as to MH/SUD
benefits. Plans and issuers must assign covered intermediate MH/SUD
benefits (such as residential treatment, partial hospitalization,
and intensive outpatient treatment) to the existing six classifications
in the same way that they assign intermediate medical/surgical benefits
to these classifications. For example, if a plan classifies care in
skilled nursing facilities and rehabilitation hospitals for medical/surgical
benefits as inpatient benefits, it must classify covered care in residential
treatment facilities for MH/SUD benefits as inpatient benefits. If
a plan treats home health care as an outpatient benefit, then any
covered intensive outpatient MH/SUD services and partial hospitalization
must be considered outpatient benefits as well. An issuer must apply
its methodology consistently when classifying covered benefits and
use the same classification for both the QTL and NQTL analyses.