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Detailed steps for applying this rule:
To determine compliance, each type of financial requirement or QTL within a coverage unit must
be analyzed separately
within each classification. See 26 CFR 54.9812-1(c)(2)(i), 29 CFR
2590.712(c)(2)(i), 45 CFR 146.136(c)(2)(i). Coverage unit refers to the way in which a plan
groups individuals for purposes of determining benefits, or premiums or contributions, for
example, self-only, family, or employee plus spouse. See 26 CFR 54.9812-1(c)(1)(iv), 29 CFR
2590.712(c)(1)(iv), 45 CFR 146.136(c)(1)(iv). If a plan applies
different levels of a financial
requirement or QTL to different coverage units in a classification of medical/surgical benefits
(for example, a $15 copayment for self-only and a $20 copayment for family coverage), the
predominant level is determined separately for each coverage
unit. See 26 CFR 54.9812-
1(c)(3)(ii), 29 CFR 2590.712(c)(3)(ii), 45 CFR 146.136(c)(3)(ii).
•
STEP ONE (“substantially all” test):
First determine if a particular type of financial
requirement or
QTL applies to substantially all medical/surgical
benefits in the relevant
classification of benefits.
•
Generally, a financial requirement or
QTL is considered to apply to substantially all
medical/surgical benefits if it applies to at least two-thirds of the medical/surgical
benefits in the classification. See 26 CFR 9812-1(c)(3)(i)(A), 29 CFR
2590.712(c)(3)(i)(A), 45 CFR 146.136(c)(3)(i)(A). This two-thirds calculation is
generally based on the dollar amount of plan payments expected to be paid for the plan
year within the classification. See 26 CFR 54.9812-1(c)(3)(i)(C), 29 CFR
2590.712(c)(3)(i)(C), 45 CFR 146.136(c)(3)(i)(C).
Any reasonable method can be
used for this calculation. See 26 CFR 54.9812-1(c)(3)(i)(E), 29 CFR
2590.712(c)(3)(i)(E), 45 CFR 146.136(c)(3)(i)(E).
• STEP TWO (“predominant” test): If the type of financial requirement or QTL applies to
at least two-thirds of medical/surgical benefits in that classification, then determine the
predominant level of that type of financial
requirement or QTL that applies to the
medical/surgical benefits that are subject to that type of financial requirement or QTL in
that classification of benefits. (Note: If the type of financial requirement or QTL does not
apply to at least two-thirds of medical/surgical benefits in that classification, it cannot
apply to MH/SUD benefits in that classification.)
•
Generally, the level of a financial requirement or QTL that is considered the
predominant level of that type is the level that applies to more than one-half
of the
medical/surgical benefits in that classification subject to the financial requirement or
QTL. See 26 CFR 54.9812-1(c)(3)(i)(B)(1), 29 CFR
2590.712(c)(3)(i)(B)(1), 45 CFR
146.136(c)(3)(i)(B)(1). If 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 can combine levels until the combination of
levels applies to more than
one-half of medical/surgical benefits subject to the
financial requirement or QTL in the classification. In that case, the least restrictive
level within the combination is considered the predominant
level.
See 26 CFR
54.9812-1(c)(3)(i)(B)(2), 29 CFR 2590.712(c)(3)(i)(B)(2), 45 CFR
146.136(c)(3)(i)(B)(2). For a simpler method of compliance, a plan may treat the