Plans years beginning on or after October 3, 2009 must comply with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) which requires group health plans and health insurance issuers to provide mental health or substance use disorder benefits on the same level as their medical or surgical benefits. This applies to private and public group health plans with over 50 employees. Self-insured plans must comply with MHPAEA. The MHPAEA does not require a group health plan to provide any mental health or substance use disorders. It only requires equal treatment between medical/surgical and mental health/substance use disorder benefits if they are both offered under the plan.
Group health plans that are subject to the MHPAEA are subject to three main requirements.
- Annual and/or Lifetime Limits
- This means that those group health plans that apply annual and/or lifetime dollar limits for medical/surgical benefits must apply those same or less restrictive dollar limits for mental health benefits and substance use disorder benefits in the same benefit classification.
- Parity as to Financial Requirements and Quantitative Treatment Limitations
- Financial requirements (such as deductibles, co-payments, co-insurance and out-of-pocket maximums) and quantitative treatment limitations (such as the number of treatments, visits or days of coverage) must be the same or less restrictive for mental health or substance use disorder as for medical/surgical benefits in the same benefit classification.
- Parity as to Nonquantitative Treatment Limitations
- Things such as medical management standards must also be treated equally or less restrictive for mental health or substance use disorder benefits as they are for medical/surgical benefits in the same benefit classification.
Measuring Plan Benefits
The rules established six classifications of benefits and the parity requirements are applied on a classification-by-classification basis.
- Inpatient, in-network
- Inpatient, out-of-network
- Outpatient, in-network
- Outpatient, out-of-network
- Emergency care
- Prescription drugs
Whether a benefit is a medical/surgical benefit or a mental health/substance use disorder benefit is determined by the generally recognized standards of current medical practice, such as the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the most current version of the International Classification of Diseases (ICD), or State guidelines. These benefits also include benefits for items as well as services. Medical conditions, surgical procedures, mental health conditions and substance use disorders are to be defined under the terms of the plan or coverage and in accordance with applicable Federal and State law.
Mental health/substance use disorder treatment limitations must be “no more restrictive than the predominant treatment limitations applied to substantially all” medical/surgical benefits covered by the plan. This phrase has three tests in it:
- is the limitation applied to substantially all medical/surgical benefits;
- is it the predominant treatment limitation; and
- is it more restrictive in the mental health/substance use disorder benefit than in the medical/surgical benefit?
- “Substantially all” means a treatment limitation that applies to at least ⅔ of the benefits in a classification. If a treatment limitation does not apply to this limit, then the treatment limitation cannot be applied to mental health/substance use disorder benefits in that classification.
- “Predominant” means the treatment limitation applies to at least ½ of the benefits in a classification. If a treatment limitation does not apply to this limit, then the treatment limitation cannot be applied to mental health/substance use disorder benefits in that classification.
Final regulations were issued in November 2013. They apply to group health plans for plan years beginning on or after July 1, 2014 (January 1, 2015 for calendar-year plans). Until then, plans must continue to comply with the interim final regulations, which have been in place for a few years already.
MHPAEA does not apply to small employers who have fewer than 51 employees and neither to individual and small group plans that are grandfathered. However, States may have other laws on this matter and small employers must be aware of the Essential Health Benefits requirement (detailed later).
In addition to the federal guidance, Missouri issued additional rules on mental health parity.
- Depending on the mental health condition, residential treatment may or may not be covered.
- Residential treatment of chemical dependency is covered by both individually underwritten and group health plans.
- All other mental health conditions, if classified in the Diagnostic and Statistical Manual of Mental Disorders IV, would be covered as well.
- If a plan chooses to place a limit on anti-depressants under their prescription coverage, they cannot place a greater financial burden on the insured than for access to treatment for a physical health condition.
- Carriers for group health plans must provide coverage for medically necessary treatment of learning disabilities, developmental delays, and mental retardation and autistic disorders.
- Insurance Carriers are able to determine what is “medically necessary.” MHPAEA requires insurance plans to make their medical necessity criteria available to current or potential participants. If denied, the health plan must inform participants why a claim has been denied, whether due to decisions about medical necessity or other reasons.
- Self-funded plans, whether they fall under ERISA or not, are not subject to the Missouri regulations, however, they are subject to the MHPAEA.
Illinois law requires employer groups of 51 or more employees to provide mental health or substance use benefits.
- Illinois law requires insurance companies and HMOs that provide group coverage for hospital or medical benefits to offer coverage for the treatment of mental illnesses, other than “serious mental illnesses” to the group policyholder regardless of the group size. If the policyholder accepts, the policy must provide benefits for serious mental illnesses.
- Serious mental illness is defined under Illinois criteria by the DSM as:
- Paranoid and other psychotic disorders;
- Bipolar disorders (hypomanic, manic, depressive and mixed);
- Major depressive disorders (single episode or recurrent);
- Schizoaffective disorders (bipolar or depressive);
- Pervasive developmental disorders;
- Obsessive-compulsive disorders;
- Depression in childhood and adolescence;
- Panic disorder;
- Post-traumatic stress disorders (acute, chronic, or with delayed onset); and
- Anorexia Nervosa and Bulimia Nervosa
- Individual insurance policies are not required by Illinois law to provide coverage to treat mental illnesses but HMO individual policies are required to provide the following benefits in accordance with state law.
- 10 days inpatient mental health care per year. Care in a day hospital, residential non-hospital or intensive outpatient mode may be substituted on a two-to-one basis for inpatient hospital services as deemed appropriate by the primary care physician.
- 20 individual outpatient mental health care visits per enrollee per year, as appropriate for evaluation, short-term treatment and crisis intervention services. Group outpatient mental health care visits may be substituted on a two-to-one basis for individual mental health care visits as deemed appropriate by the primary care physician.
Coverage for serious mental illness in Illinois requires parity with respect to financial requirements such as dollar limits, deductibles and coinsurance requirements. Subject to medical necessity determination, in each calendar year, coverage for these benefits cannot be less than;
- 45 days of inpatient treatment,
- 60 visits for outpatient treatment, and
- 20 additional outpatient visits for speech therapy for treatment of pervasive developmental disorders.
Affordable Care Act Interactions
- Starting in 2014, all small group and individual market plans created before March 23, 2010 must comply with federal parity requirements.
- Qualified Health plans offered through the Health Insurance Marketplaces in every state must include coverage for mental health and substance use disorders as one of the ten categories of essential health benefits and that coverage must comply with the federal parity requirements set forth in MHPAEA.
Essential Health Benefits
The Affordable Care Act also impacts the mental health parity law through some of its laws. MHPAEA does not apply directly to small group health plans, but its requirements are indirectly applied through the Essential Health Benefit (EHB) requirements. Non-grandfathered health insurance coverage in the individual and small group markets, through an Exchange or outside of an Exchange, must comply with the requirements of MHPAEA regulations to satisfy the EHB requirement. These requirements are that a plan must provide EHBs, limit cost-sharing and provide either bronze, silver, gold or platinum level coverage or a catastrophic plan. The ten categories of EHB include:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavior health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care.
“Carve-out” health benefits are mental health benefits that are purchased by employers separately from medical benefits. This poses a challenge to the implementation of MHPAEA since it may be separate from the vendor providing medical benefits. If so, the law would require the “carve-out” vendor to ensure parity with medical benefits provided by another vendor.
ERISA contains no specific penalty or enforcement rule for violations of MHPA or the MHPAEA. However, participants, beneficiaries, and the Department of Labor may use ERISA’s civil enforcement provisions to file lawsuits to enforce the MHPA’s and MHPAEA’s requirements.
This lawsuit could include breach of fiduciary duty for failure to comply with the MHPA or MHPAEA, claims for payment or mental health benefits alleged to be due, and damages for unpaid benefits, interest and attorney’s fees.
The IRS may impose excise taxes for a group health plan’s failure to comply of $100 per day for each individual to whom a failure relates.
For more information:
See the original article here:
Mental <b>Health</b> Parity and Addiction Equity Act | TerrillConnect <b>…</b>