| (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
(ii) all other outpatient items and services (such
as outpatient surgery, facility charges for day treatment centers,
laboratory charges, or other medical items).
(4) Examples. The requirements of paragraph (3)(A)
- (C) of this subsection are illustrated by examples provided in figure
28 TAC §21.2408(c)(4). 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
(5) No separate cumulative financial requirements or
cumulative quantitative treatment limitations.
(A) A health benefit plan may not apply any cumulative
financial requirement or cumulative quantitative treatment limitation
for mental health or substance use disorder benefits in a classification
that accumulates separately from any established for medical/surgical
benefits in the same classification.
(B) The requirements of this paragraph are illustrated
by examples provided in figure 28 TAC §21.2408(c)(5)(B).
Attached Graphic
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