| (a) Separate worksheet and analysis for each classification
and subclassification. Within the QTL template are separate worksheets,
named for each classification or subclassification (classification
worksheets) identified in §21.2436(e) of this title (relating
to Quantitative Parity Analysis: Covered Benefits). If an issuer's
plan design applies a QTL or financial requirement to a MH/SUD benefit
in a given classification or subclassification, the issuer must document,
in the applicable classification worksheet, the following:
(1) in Column 1 of each classification worksheet: the
dollar amount or per member per month amount of all plan payments
expected to be paid under the plan for the plan year consistent with §21.2408(c)(1)(C)
- (E) of this title (relating to Parity Requirements with Respect
to Financial Requirements and Treatment Limitations);
(2) in Column 2 of each classification worksheet: whether
a copay applies and, if applicable, the copay amount;
(3) in Column 3 of each classification worksheet: whether
a coinsurance applies and, if applicable, the coinsurance percentage
amount;
(4) in Column 4 of each classification worksheet: whether
a deductible applies and, if applicable, the deductible amount;
(5) in Column 5 of each classification worksheet: whether
a session limit applies and, if applicable, the session limit quantity;
and
(6) in Column 6 of each classification worksheet: whether
a day limit applies to each service category and, if applicable, the
day limit quantity.
(b) "Substantially all" test. Consistent with §21.2408(c)(1)(A)
of this title, an issuer must perform the following calculations separately
in each classification worksheet to determine whether a QTL or financial
requirement that applies to MH/SUD benefits also applies to substantially
all medical/surgical benefits.
(1) To calculate the aggregate total of expected plan
payments for medical/surgical benefits in the classification worksheet,
add the dollar amounts listed in every row of Column 1.
(2) To determine whether a copay applies to substantially
all medical/surgical benefits in the classification worksheet:
(A) for every row in Column 2 of the worksheet with
a copay amount listed greater than $0, add the expected plan payment
amounts for the benefit listed in Column 1 of that row; and
(B) divide the amount in subsection (b)(2)(A) of this
section by the aggregate total calculated under subsection (b)(1)
of this section.
(3) To determine whether a coinsurance applies to substantially
all medical/surgical benefits in the classification worksheet:
(A) for every row in Column 3 of the worksheet with
an enrollee coinsurance amount listed greater than $0, add the expected
plan payment amounts for the benefit listed in Column 1 of that row;
and
(B) divide the amount addressed in subsection (b)(3)(A)
of this section by the aggregate total calculated under subsection
(b)(1) of this section.
(4) To determine whether a deductible applies to substantially
all medical/surgical benefits in the classification worksheet:
(A) for every row in Column 4 of the worksheet with
a deductible amount listed greater than $0, add the expected plan
payment amounts for the benefit listed in Column 1 of that row; and
(B) divide the amount addressed in subsection (b)(4)(A)
of this section by the aggregate total calculated under subsection
(b)(1) of this section.
(5) To determine whether a session limit applies to
substantially all medical/surgical benefits in the classification
worksheet:
(A) for every row in Column 5 of the worksheet with
a session limit listed that is less than unlimited, add the expected
plan payment amounts for the benefit category listed in Column 1 of
that row; and
(B) divide the amount addressed in subsection (b)(5)(A)
of this section by the aggregate total calculated under subsection
(b)(1) of this section.
(6) To determine whether a day limit applies to substantially
all medical/surgical benefits in the classification worksheet:
(A) for every row in Column 6 of the worksheet with
a day limit listed that is less than unlimited, add the expected plan
payment amounts for the benefit listed in Column 1 of that row; and
(B) divide the amount addressed in subsection (b)(6)(A)
of this section by the aggregate total calculated under subsection
(b)(1) of this section.
(7) If the amount calculated under any of the paragraphs
in subsections (b)(2) - (b)(6) of this section is less than two-thirds
on any of the classification worksheets, the financial requirement
or quantitative treatment limitation in that paragraph fails the "substantially
all" test under §21.2408(c)(1)(A) of this title and cannot be
applied to a MH/SUD benefit.
(c) "Predominant" test. Consistent with §21.2408(c)(1)(B)
of this title, the issuer must separately perform the following calculations
in each classification worksheet, as applicable, to determine whether
the level of a type of quantitative treatment limitation or financial
requirement that satisfied the "substantially all" test in subsection
(b) of this section is no less favorable than the predominant quantitative
treatment limitation or financial requirement that applies to medical/surgical
benefits.
(1) Calculate the aggregate total of expected plan
payments for medical/surgical benefits within each classification
or subclassification that is subject to a particular type of financial
requirement or quantitative treatment limitation. Separately, in Columns
2 through 6 of the classification worksheet, for every row with an
amount listed, add the expected claim dollar amounts from Column 1
of the worksheet for the benefit listed in that row.
(2) To determine whether the level of a financial requirement
or quantitative treatment limitation applied to MH/SUD is not less
favorable than the predominant financial requirement or quantitative
treatment limitation applied to medical/surgical benefits, follow
the instructions in the following subparagraphs for each financial
requirement and quantitative treatment limitation identified in Columns
2 through 4 of each classification worksheet.
(A) Rank each level of each type of financial requirement
and quantitative treatment limitation from highest to lowest.
(B) For each level of each type of financial requirement
and quantitative treatment limitation identified in Columns 2 through
4 of the classification worksheet, add the expected plan payments
identified in Column 1 of the worksheet for each benefit to which
the level of financial requirement or quantitative treatment limitation
applies.
(C) Divide each amount calculated under subsection
(c)(2)(B) of this section by the aggregate total addressed in subsection
(c)(1) of this section.
(D) Add the amounts calculated under subsection (c)(2)(C)
of this section for each level of each type of financial requirement
and quantitative treatment limitation identified in Columns 2 through
4 of the classification worksheet, from highest to lowest, until the
aggregate total exceeds 50%.
(E) In each of the classification worksheets, the least
restrictive level of each type of financial requirement or quantitative
treatment limitation calculated under subsection (c)(2)(D) of this
section to exceed 50% is the predominant level and the least restrictive
level that can be applied to MH/SUD benefits. For example:
(i) for copays, coinsurance, and deductibles, the predominant
level is the highest amount that can be applied to MH/SUD benefits;
and
(ii) for day limits and session limits, the predominant
level is the lowest level of day or session limits that can be applied
to MH/SUD benefits.
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