Proposed guidance clarifies how mental-health parity rules apply to benefit limits
|By Julia Zuckerman and Lysle Laderman © ConduentMay 16, 2018
The Departments of Labor (DOL), Treasury, and Health and Human Services (HHS) recently issued guidance that clarifies how mental-health parity rules apply to benefit limits, such as pre-authorization and medical-management techniques, with specific examples of parity standards for experimental or investigative treatment limits, drug-formulary design and provider networks.
The guidance package, which the departments issued on April 23, was comprised of:
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) generally prohibits group health plans that provide mental health or substance-use disorder (MH/SUD) benefits from imposing less favorable conditions or more stringent limits on those benefits than they do on the same classification of medical and surgical benefits. This federal law requires parity in financial requirements (like deductibles or co-payments) and quantitative treatment limits (such as number of covered visits). It also requires parity in nonquantitative treatment limits, which are non-numerical limits on the scope or duration of benefits, such as a pre-authorization requirement or a medical-management technique.
MHPAEA does not require a plan to cover any specific MH/SUD conditions; rather, it requires that if it covers an MH/SUD condition, it covers it in parity with medical/surgical benefits. Also, MHPAEA does not apply to retiree-only plans or to excepted benefits.
Participants, beneficiaries, and the DOL may file claims for payment of mental health benefits under the law's civil enforcement provisions. Failure to comply with MHPAEA also may trigger an excise tax of $100 per day for each individual to whom a failure relates, under Internal Revenue Code Section 4980D.
As part of its 2017 MHPAEA enforcement efforts, the DOL reviewed 187 group health plans and identified 92 MHPAEA violations. Additionally, it answered over 127 public inquiries in 2017 relating to MHPAEA.
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The proposed FAQs identify certain plan features as nonquantitative treatment limits that violate (and, in a few cases, do not violate) parity requirements. For instance, a plan may not unconditionally exclude all experimental or investigative treatments for MH/SUD conditions while covering certain experimental or investigative treatments for medical and surgical conditions on a treatment-by-treatment basis.
It's unusual for subregulatory guidance like FAQs to be proposed for notice and comment, a process typically reserved for proposed regulations. The departments may have chosen this approach to retain the flexibility of subregulatory guidance while incorporating specific stakeholder feedback.
Revised Disclosure Template
The proposed disclosure template is designed to help participants and beneficiaries request information on any limitations that may affect their MH/SUD benefits, with the idea of enabling them to evaluate parity. The draft form, which participants and beneficiaries can use to request information from plans even though it has not yet been finalized, gives the plan 30 days to respond to these requests.
The self-compliance tool, which the DOL intends to update every two years to reflect any additional MHPAEA guidance, is designed to assist plan sponsors in determining whether their plans comply with MHPAEA requirements. Plan sponsors can use the tool to review plan terms and policies, and to monitor those of vendors or carriers to confirm MHPAEA compliance.
Focus on Enforcement
The guidance suggests that, a decade after MHPAEA's enactment, enforcement is now a stronger priority than ever.
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Source: The Society For Human Resource Management (SHRM)