On November 13, 2013, the Departments of Health and Human
Services (HHS), Labor, and the Treasury published a joint final rule implementing the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity Act of 2008
(MHPAEA). The MHPAEA requires group health insurance plans to
provide parity between mental health or substance use disorder
benefits and medical/surgical benefits with respect to financial
requirements (e.g., copayments and deductibles) and treatment
limitations. The MHPAEA's statutory provisions generally were
effective for plan years beginning after October 3, 2009. Interim final rules published February 2, 2010
generally became applicable for plan years beginning on or after
July 1, 2010.
The November 13, 2013 final rule builds on the interim rule and
additional clarifications subsequently issued by the Departments,
and provides clarification of provisions intended to strengthen
consumer protections. For instance, the final rule removes an
interim final rule exception to the nonquantitative treatment
limitations (NQTL) requirements ''to the extent that
recognized clinically appropriate standards of care may permit a
difference." The Departments note that while the regulations
do not require plans and issuers to use the same NQTLs (e.g.,
medical management techniques like prior authorization) for both
mental health and substance use disorder benefits and
medical/surgical benefits, the processes, strategies, evidentiary
standards, and other factors used to determine whether and to what
extent a benefit is subject to an NQTL must be comparable to and
applied no more stringently for mental health or substance use
disorder benefits than for medical/surgical benefits. In addition,
the final rule: clarifies the applicability of parity requirements
to intermediate levels of care received in residential treatment or
intensive outpatient settings; addresses the scope of the
transparency required by health plans; and provides that plan or
coverage restrictions based on geographic location, facility type,
provider specialty, and other criteria that limit the scope or
duration of benefits for services must comply with the NQTL parity
standard. The November 13 final rule generally applies to plan
years beginning on or after July 1, 2014; until then plans and
issuers subject to MHPAEA must continue to comply with the interim
Note that the Affordable Care Act (ACA) separately includes
mental health and substance use disorder services as an
"essential health benefits" category that must be
provided by health plans offered in the individual and small group
markets beginning in 2014.
This article is presented for informational purposes only
and is not intended to constitute legal advice.
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On September 8, 2014, the U.S. Department of Justice (DOJ) filed a False Claims Act (FCA) case in the Central District of California against Reliance Medical Systems, two related distributors (Apex Medical Technologies and Kronos Spinal Technologies), and several of their physician owners, based on the theory that investment returns from these physician-owned distributors (PODs) were unlawful kickbacks.