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:
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.
Design benefit plans and respond quickly and confidently to a range of potential issues with a free trial to the Benefits Practice Resource Center.
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