Group health plan sponsors recently received updated guidance (in form of a FAQ) from the Departments of Labor, Health and Human Services, and the Treasury regarding compliance with mental health parity.
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) was established to prohibit plans from imposing less favorable restrictions on mental health and substance use disorder benefits when compared to medical or surgical benefits. For example, MHPAEA requires the “financials” (deductibles, coinsurance, copays, visit limits, etc.) for mental health and substance use disorder to be no more restrictive than those that apply to medical conditions.
Some examples of these less favorable restrictions (also called “nonquantitative treatment limitations”) are as follows:
(1) Medical management limits or excluding benefits based on medical necessity. For example, applying guidelines more strictly for substance use disorder (and mental health?) than other medical conditions.
(2) Prior authorizations. Excluding inpatient coverage for eating disorders does not comply with MHPAE.
(3) Refusal to pay for higher cost therapies until it is proven that lower cost treatment is not effective. While the financial components are usually easily determined, the nonquantitative treatment limitations may require additional review of medical policy guidelines and scrutiny by carriers, administrators, and employers to determine compliance with MHPSEA.
The new guidance also provided several examples of nonquantitative treatment limitations that would be impermissible:
(Denial of) Behavioral Analysis to treat Autism Spectrum Disorder, even though it meets the requirements above, does not comply with the MHPAEA based on the most recent guidelines.
The new guidance also requires that medical necessity determinations and reason for denials for mental health and substance use disorder be made available to the participant within 30 days of the participant’s request. With this new guidance, the government agencies provide additional protections to the 40 million individuals that experienced mental illness and the 20 million individuals that had a substance abuse disorder this past year.
If you have questions or concerns on whether your plan is compliant with the new guidelines, please contact us.