Information contained in this publication is intended for informational purposes only and does not constitute legal advice or opinion, nor is it a substitute for the professional judgment of an attorney.
The Department of Labor’s Employee Benefits Security Administration (EBSA) has issued a new set of Frequently Asked Questions (FAQs) on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). This law generally requires private group health benefit plans that provide mental health and/or substance use disorder benefits through a group health benefit plan that also offers medical and surgical benefits to do so on an equivalent basis. The Act imposes several plan design requirements on group health benefit plans that offer mental health and/or substance use disorder benefits including equity in cost sharing, treatment limitations, and coverage decision requirements. For example, the MHPAEA and its implementing regulations stipulate that plans and issuers may not impose a lifetime or annual dollar limit on mental health or substance use disorder benefits that is lower than the lifetime or annual dollar limit imposed on medical/surgical benefits.
The recently-issued guidance includes a set of 10 FAQs covering such topics as which agencies oversee the MHPAEA’s implementation, whether certain plan designs violate the MHPAEA, and how to seek redress if an individual believes his or her plan is in violation of the law.
Among other points, the FAQs explain that:
- A plan that provides medical/surgical benefits on an outpatient basis may not limit mental health or substance use disorder benefits to inpatient care only.
- The MHPAEA requires that mental health and substance use disorder benefits be covered and managed in a manner that is no more stringent than medical/surgical benefits, but does not require that insurance arrangements be organized in any particular way. Therefore, a health plan that uses a separate managed behavioral health organization to provide utilization review and other services with respect to mental health and/or substance abuse benefits (a “carve-out” arrangement) would not necessarily violate the MHPAEA.
- Nonquantitative treatment limitations (NQTLs) such as medical management standards are not analyzed in the same way as are financial or quantitative treatment limitations on mental health/substance use disorder benefits. According to the FAQs, the interim final regulations on the MHPAEA explain that with respect to NQTLs, “under the terms of the plan as written and in practice, any processes, strategies, evidentiary standards, or other factors used by a plan or issuer in applying an NQTL to mental health or substance use disorder benefits must be comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation to medical/surgical benefits, unless recognized clinically appropriate standards of care may permit a difference.”
- States generally may impose stricter requirements regarding mental health benefits on health insurance issuers.
- The MHPAEA does not apply to employers who have fewer than 51 employees.
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