Section Ins 2702.06 - Financial Requirements and Quantitative Treatment Limitations(a) Determining "substantially all" and "predominant." For purposes of applying the general parity requirements, 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. 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 shall not be applied to mental health or substance use disorder benefits in that classification.(b) Predominant. (1) If a type of financial requirement or quantitative treatment limitation applies to at least two-thirds for all medical/surgical benefits in a classification, 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.(2) 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, and 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 health issuer 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 health issuer 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 applying the general parity requirements, 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 payments for medical/surgical benefits in the classification expected to be paid for the plan year, or for the portion of the plan year after a change in benefits that affects the applicability of the financial requirement or quantitative treatment limitation.(d) Clarifications for certain threshold requirements. For any deductible or other type of threshold requirement in the policy, the dollar amount of payments includes all 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 payments includes all payments associated with out-of-pocket payments that are taken into account towards the out-of-pocket maximum as well as all payments associated with out-of-pocket payments that would have been made towards the out-of-pocket maximum if it had not been satisfied.(e) Application to different coverage units. If group health insurance coverage issued to a large employer applies different levels of a financial requirement or quantitative treatment limitation to different coverage units or membership tiers in a classification of medical/surgical benefits, the predominant level that applies to substantially all medical/surgical benefits in the classification shall be determined separately for each coverage unit.(f) Special rule for multi-tiered prescription drug benefits. If group health insurance coverage issued to a large employer applies different levels of financial requirements to different tiers of prescription drug benefits based on factors determined in accordance with the general rules of the coverage plan relating to requirements for nonquantitative treatment limitations, 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 large group health insurance coverage shall be considered as satisfying the parity requirements with respect to prescription drug benefits. Reasonable factors include cost, efficacy, generic versus brand name, and mail order versus pharmacy pick-up.(g) No separate cumulative financial requirements or cumulative quantitative treatment limitations. Group health insurance coverage issued to a large employer shall 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 medical/surgical benefits in the same classification.(h) 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).N.H. Admin. Code § Ins 2702.06
The amended version of this section by New Hampshire Register Volume 38, Number 50, eff. 12/3/2018 is not yet available.