The Departments of Labor, Treasury, and Health and Human Services (the Departments) recently released guidance and a request for comments on certain aspects of the Mental Health Parity and Addiction Equity Act (MHPAEA)1 and the 21st Century Cures Act (the Act), which required the Departments to take steps in 2017 to strengthen enforcement of the MHPAEA.2 The Act required the Departments to solicit public feedback on how to improve the process participants can use to request information from a health plan about the plan’s compliance with the MHPAEA. The Act also clarified that if provided, coverage for eating disorders, including residential treatment, must be consistent with the MHPAEA.
This Update provides background information on the MHPAEA and summarizes the new guidance. Comments on this guidance are due by September 13, 2017.
The MHPAEA requires parity between medical/surgical benefits and mental health/substance use disorder (MH/SUD) benefits. Health plans must provide parity in both numerical or “quantitative” financial requirements or treatment limits (e.g., cost sharing and day or visit limits) and “non-quantitative” treatment limits, which are described in the text box below. The MHPAEA requires that plan administrators provide upon request to any current or potential participant, beneficiary or contracting provider detailed criteria for medical necessity determinations relating to MH/SUD.
What Are “Non-quantitative” Treatment Limits?
“Non-quantitative” Treatment Limits (NQTLs) are tools to manage the mental health or substance use disorder benefit.* Examples include:
* For a discussion of the evidence-based process that plan sponsors must follow and document to support the application of medical management tools to MH/SUD care, see Sibson’s July 25, 2016 Update, “Mental Health Parity and Addiction Equity Act Enforcement Is a Priority for Federal Agencies.”
The Departments issued a Frequently Asked Question (FAQ) concerning how the MHPAEA applies to benefits offered for treatment of an eating disorder, and solicited comments on whether any additional clarification is necessary.
The guidance states that eating disorders are mental health conditions, and therefore treatment of an eating disorder is a “mental health benefit” as defined by MHPAEA.
Eating disorders include disorders such as anorexia nervosa, bulimia nervosa, binge-eating disorder and other conditions. Plans that cover treatment for eating disorders must assure that the financial cost sharing and limits on eating disorder treatments are no more restrictive than those for medical/surgical treatment. In addition, plans should assure that any medical management tools, such as prior authorization requirements, are not applied in a more restrictive manner for eating disorders when compared to their application to medical/surgical conditions.
The Departments published a draft model form that participants, enrollees or their authorized representatives could — but would not be required to — use to (1) request information from their health plan or insurer regarding MH/SUD benefits, or (2) to obtain documentation after an adverse benefit determination involving MH/SUD benefits to support an appeal.3 The Departments request comments on any aspect of the draft model form and the Departments’ outline of how plans should respond to information requests.
The draft model form is not an appeal form, although it states that information obtained can help the individual appeal a denial. The form requests that the plan provide the requested information within 30 calendar days of the date of the request. Plans would be required to provide:
Plan sponsors should assure that coverage for eating disorders complies with the MHPAEA. This would include taking a detailed look at any treatment limitations or authorization rules to assure that they are not more restrictive than those applied to medical/surgical treatments.
In addition, plan sponsors already must respond to requests for information from participants and beneficiaries, and should be prepared to demonstrate that any treatment limitations or medical-management criteria, such as prior authorization or utilization review standards, are no more restrictive than those applied to medical or surgical benefits. Plans that wish to comment on the details of the form should review it and do so no later than September 13, 2017.
Sibson works with plan sponsors and their legal counsel on compliance issues. Sibson can review plan documents and operations and make recommendations with respect to compliance with the MHPAEA; estimate the cost implications of plan design changes needed to comply with the MHPAEA; draft plan amendments; and draft participant communications explaining changes to the benefits.
For more information about how these new rules may affect your plan, please contact your Sibson consultant or the Sibson office nearest you.
1 The guidance is available on the Department of Labor (DOL) website.
2 The 21st Century Cures Act (Public Law 114-255) was enacted December 13, 2016. For a summary of the Act, see Sibson’s Consulting’s February 15, 2017 Update, “21st Century Cures Act Enhances Mental Health Parity Oversight and Creates New Small Employer Health Reimbursement Arrangement.”
3 The draft model form is available on the DOL website.
Update is Sibson Consulting’s electronic newsletter summarizing compliance news. Update is for informational purposes only and should not be construed as legal advice. It is not intended to provide guidance on current laws or pending legislation. On all issues involving the interpretation or application of laws and regulations, plan sponsors should rely on their attorneys for legal advice.
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