HHS, DOL and IRS (the “Agencies”) have jointly issued proposed FAQs to provide guidance on the implementation of the requirements of the Mental Health Parity and Addiction Equity Act of 2008 (the “MHPAEA”).
Background. In general, MHPAEA requires that the financial requirements (e.g., coinsurance and copays) and treatment limitations (e.g., visit limits) imposed on mental health or substance use disorder (“MH/SUD”) benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits in a classification.
With regard to any non-quantitative treatment limitation (“NQTL”), the MHPAEA final regulations provide that a group health plan or health insurance issuer may not impose a NQTL with respect to MH/SUD benefits in any classification unless, under the terms of the plan (or health insurance coverage) as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation to medical/surgical benefits in the same classification.
MHPAEA also imposes certain disclosure requirements on group health plans and health insurance issuers.
Proposed FAQs. Among other things the proposed FAQs clarify that under MHPAEA:
- A health plan cannot:
- Deny (as experimental or investigative) claims for Applied Behavioral Analysis therapy to treat children with Autism Spectral Disorder that is supported by professionally-recognized treatment guidelines when the plan approves treatment for medical/surgical conditions that are supported by similar guidelines.
- Set dosage limits for prescription drugs used to treat MH/SUD disorders that are less than the professionally-recognized treatment guidelines, when the dosage limits set by the plan for medical/surgical benefits equal or exceed the treatment guideline limits.
- Pay reduced reimbursement rates to non-physician practitioners providing MH/SUD services where the plan does not pay reduced reimbursement rates to non-physician practitioners who provide medical/surgical services.
- Exclude coverage for inpatient, out-of-network treatment outside of a hospital for eating disorders (e.g., a residential treatment center) when the plan covers such treatments for medical/surgical conditions when there is physician authorization and determination that the treatment is medically appropriate based on clinical standards of care.
- An exclusion of all benefits for a particular condition or disorder is not a treatment limitation for purposes of the definition of “treatment limitations” in the MHPAEA regulations. For example, under MHPAEA a group health plan may contain a general exclusion for items and services to treat bipolar disorder, including prescription drugs.
NOTE: Small employer group health insurance coverage and individual health insurance coverage are subject to the ACA requirement to provide essential health benefits (“EHB”s), and the determination of whether certain benefits must be covered depends on the applicable state’s EHB benchmark plan.
- If a health plan uses a provider network, its SPD must provide a general description of the network along with a listing of providers that is up-to-date, accurate and complete.
NOTE: The provider list may be furnished in a separate document that is accompanied by the plan’s SPD if it is furnished automatically and without charge and the SPD contains a statement to that effect.
- Health plans that utilize provider networks can satisfy applicable disclosure requirements by providing a hyperlink or URL address in enrollment and plan summary materials for a provider directory where information related to MH/SUD providers can be found.
The proposed FAQs are available at: https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-39-proposed.pdf