HEALTH PLANS: FINDING PARITY FOR MENTAL HEALTH BENEFITS AND OPIOID TREATMENT

 

Exam Room

Group health plans can’t impose stricter financial requirements or treatment limitations on mental health and substance use disorder benefits than they do for medical and surgical benefits, federal agencies emphasized in a recent set of FAQs. 

In the 34th set of frequently-asked-questions about Affordable Car Act implementation published by the IRS, DOL, and HHS Oct. 28, the agencies offer clarification on the Mental Health Parity and Addiction Equity Act of 2008.  

Under MHPAEA, as amended by the ACA, non-grandfathered individual and small group plans must cover mental health and substance use disorder services as one of 10 essential health benefit categories.

The FAQs cover quantitative treatment limitations, nonquantitative treatment limitations and MHPAEA disclosure obligations and include a request for comments.  

Under the MHPAEA, treatment limitations are limits to the scope or duration of treatment. Quantitative treatment limitations are limits to the frequency of treatment, such as a day limit or visit limit.  

The FAQs offer guidance to group plans unsure of how to calculate quantitative treatment limitations. MHPAEA regulations state that the quantitative treatment limitations must apply to at least two-thirds of medical and surgical benefits in order to be applied to mental health and substance use disorder benefits. The calculation should be based on the dollar amount of all plan payments for medical and surgical benefits and plans can use any “reasonable method” to determine that dollar amount.  

A reasonable method could include claims data in compliance with applicable Actuarial Standards of Practice, according to the FAQs. However, it should not include an issuer’s or third party administrator’s broad book of business because it could include multiple unrelated plan designs. The FAQs advise plans to document the assumptions used in choosing a data set and making projections.  

Nonquantative treatment limitations include limits based on medical necessity, medical management standards or a network tier design that includes preferred providers and participating providers. 

The FAQs provide some examples of impermissible nonquantitative treatment limitations: 

  • Plans that require prior authorization by a plan representative for medical or surgical inpatient in-network admissions over the phone may not require an-in person examination by a plan representative for inpatient in-network admissions at a mental health facility. 
  • Plans that require participants to enroll in an outpatient program before they will authorize coverage for inpatient program to treat medical or surgical conditions may impose the same conditions for substance use disorders unless there are no intensive outpatient programs available in a participant’s geographic area. 
  • Plans that do not impose authorization from a utilization reviewer for safety risks associated with prescription drugs to treat medical or surgical conditions may not require authorization from a utilization reviewer for prescriptions to treat an opioid use disorder.
  • Plans that do not impose non-pharmacological fail-first requirements for medical or surgical conditions may not impose such requirements for coverage of opioid use disorder prescriptions.
  • Plans that follow nationally-recognized treatment guidelines for prescription drug prior authorization requirements may not require prior authorization for opioid use disorder prescription refills every 30 days.
  • Plans that do not exclude court-ordered treatment for medical or surgical conditions may not exclude court-ordered treatment for substance use disorders but may apply medical necessity criteria to treatment requests.

The FAQs were presented alongside the Mental Health and Substance Use Disorder Parity Task Force final report on parity implementation and the Mental Health and Addiction Insurance Help Consumer Portal.  The portal was designed to help consumers identify which federal or state agency can provide mental health oversight for their plan.    

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