Recent Developments in Mental Health Parity
The Mental Health Parity and Addiction Equity Act (MHPAEA) and the associated rules have been in place now for most health plans and employers for 7 years. The Interim Final Rules were effective for health plan renewals on or after July 1, 2009, while the Final Rules became effective for renewals on or after July 1, 2014. So why an article on MHPAEA now in 2016? Because we continue to see many non-compliant plan designs on the market, including designs by states and the federal government, and compliance enforcement activities appear to be picking up. And there is still that potential penalty for being found non-compliant of $100 per member per day! This article presents a summary of the parity law …show more content…
The Rules require plans to pass detailed tests of any quantitative financial requirements and treatment limits. Member cost-sharing can be applied to mental health or substance use benefits only if a particular type of cost-sharing (copay, coinsurance, deductible, etc.) is applies to Substantially All (at least two-thirds of allowed costs) of the medical/surgical benefits in the classification being tested. If cost-sharing is allowed in the classification, the Predominant level of cost-sharing must be determined (level applying to greater than 50% of the allowed costs). These same two tests apply to quantitative treatment limits as well (inpatient day limits, outpatient visit limits, …show more content…
This was in response to stakeholders asking for examples for plan provisions they might see on the mental health and substance use disorder side (MH/SUD) which should trigger careful analysis of the coverage on the medical/surgical side (med/surg) in order to ensure MHPAEA NQTL compliance. Language contained in the following provisions (absent similar restrictions on the med/surg side) can serve as a red flag that a plan or issuer may be imposing an impermissible NQTL. Further review of the processes, strategies, evidentiary standards, or other factors used in applying the NQTL to both MH/SUD and med/surg benefits will be required to determine parity compliance. Note that these plan/policy terms do not automatically violate the law, but the plan or issuer will need to provide evidence to substantiate compliance. The categories and examples below are not exhaustive and are not a substitute for any regulations or other interpretive guidance issued by the
The Mental Health Parity and Addiction Equity Act (MHPAEA) and the associated rules have been in place now for most health plans and employers for 7 years. The Interim Final Rules were effective for health plan renewals on or after July 1, 2009, while the Final Rules became effective for renewals on or after July 1, 2014. So why an article on MHPAEA now in 2016? Because we continue to see many non-compliant plan designs on the market, including designs by states and the federal government, and compliance enforcement activities appear to be picking up. And there is still that potential penalty for being found non-compliant of $100 per member per day! This article presents a summary of the parity law …show more content…
The Rules require plans to pass detailed tests of any quantitative financial requirements and treatment limits. Member cost-sharing can be applied to mental health or substance use benefits only if a particular type of cost-sharing (copay, coinsurance, deductible, etc.) is applies to Substantially All (at least two-thirds of allowed costs) of the medical/surgical benefits in the classification being tested. If cost-sharing is allowed in the classification, the Predominant level of cost-sharing must be determined (level applying to greater than 50% of the allowed costs). These same two tests apply to quantitative treatment limits as well (inpatient day limits, outpatient visit limits, …show more content…
This was in response to stakeholders asking for examples for plan provisions they might see on the mental health and substance use disorder side (MH/SUD) which should trigger careful analysis of the coverage on the medical/surgical side (med/surg) in order to ensure MHPAEA NQTL compliance. Language contained in the following provisions (absent similar restrictions on the med/surg side) can serve as a red flag that a plan or issuer may be imposing an impermissible NQTL. Further review of the processes, strategies, evidentiary standards, or other factors used in applying the NQTL to both MH/SUD and med/surg benefits will be required to determine parity compliance. Note that these plan/policy terms do not automatically violate the law, but the plan or issuer will need to provide evidence to substantiate compliance. The categories and examples below are not exhaustive and are not a substitute for any regulations or other interpretive guidance issued by the