United States: How To Comply With The Mental Health Parity And Addiction Equity Act

The Mental Health Parity and Addiction Equity Act (MHPAEA) prohibits health insurance policies and group health plans that cover mental health and substance use disorder (MH/SUD) benefits from imposing limitations on MH/SUD benefits that are less favorable than the limitations imposed on medical/surgical benefits.  

The Department of Labor’s Employee Benefits Security Administration (EBSA) is actively enforcing MHPAEA, and violations of MHPAEA are a frequent subject of lawsuits.  The purpose of this article is to provide a high-level MHPAEA compliance guide for employers who sponsor self-funded health plans.

Overview of Requirements 

Classifications.  When evaluating parity between MH/SUD and medical/surgical benefits, there are six main classifications of benefits: 

(i) inpatient, in-network; 
(ii) inpatient, out-of-network; 
(iii) outpatient, in-network; 
(iv) outpatient, out-of-network; 
(v) emergency care; and 
(vi) prescription drugs

If a plan provides MH/SUD benefits in any classification, MH/SUD benefits must also be provided in every classification in which medical/surgical benefits are provided.  The below parity requirements are applied on a classification-by-classification basis (with limited permissible subclassifications).  

Financial Requirements and Quantitative Treatment Limitations.  The financial requirements (e.g., deductibles, copayments, coinsurance, and out-of-pocket limits) and the quantitative treatment limitations (e.g., day and visit limitations) that apply to MH/SUD benefits in any classification must not be more restrictive than those applied to medical/surgical benefits in the same classification.  In addition, requirements/limitations for MH/SUD benefits may not accumulate separately from the requirements/limitations for medical/surgical benefits (e.g., a plan may not impose separate deductibles for MH/SUD and medical/surgical benefits).

Nonquantitative Treatment Limitations.  Examples of nonquantitative treatment limitations (NQTLs) are preauthorization requirements, step therapy requirements, and exclusions for failure to complete a course of treatment.  Plans are prohibited from imposing NQTLs on MH/SUD benefits unless the NQTLs are comparable to, and are applied no more stringently than, the NQTLs applied to medical/surgical benefits in the same classification. 

Self-Compliance Tool

Happily, the EBSA offers a self-compliance tool (summarized below) to assist plans in determining whether they comply with MHPAEA. 

Two-Step Test for Financial Requirements and Quantitative Treatment Limitations. 

First, confirm that the requirement or type of limit at issue applies to “substantially all” (at least two-thirds of) medical/surgical benefits in the classification.  If the first test is satisfied, then determine the predominant level of the requirement/limitation (generally, the level that applies to more than half of medical/surgical benefits subject to the requirement/limitation in the classification), and then do not impose a requirement/limitation of that type that exceeds the predominant level.  

For example, if 75% of outpatient, in-network visits involving medical/surgical services are subject to a $30 copayment, then the plan cannot impose a copayment higher than $30 for outpatient, in-network MH/SUD visits.

Four-Step Test for Nonquantitative Treatment Limitations. 

First, identify the NQTL and which classifications it applies to for both MH/SUD benefits and medical/surgical benefits. 

Second, identify the factors (e.g., excessive utilization or lack of clinical efficiency) that are considered in designing the NQTL and, if only certain benefits are subject to an NQTL, substantiate how the applicable factors were used to apply the NQTL and determine the reason(s) why certain factors were given more weight than others, if applicable.  

Third, identify the sources (e.g., internal claims analysis or medical expert reviews) used in defining the factors, and confirm they were applied comparably to MH/SUD and medical/surgical benefits.  

Fourth, evaluate whether the processes, strategies, and evidentiary standards used in applying the NQTL to MH/SUD are comparable to, and applied no more stringently than, they are applied to medical/surgical benefits, both in writing and in operation.  

Specific Benefits.  The tool clarifies that medication-assisted treatment for opioid use disorder and treatment for eating disorders are both subject to MHPAEA requirements.

Disclosure Requirements.  The tool also details MHPAEA disclosure requirements.  Specifically, upon request, the plan administrator (or health insurance issuer) must make available the criteria for medical necessity determinations with respect to MH/SUD benefits to current and potential participants, beneficiaries, and contracting providers.  The plan administrator must also provide the reasons for any denials of MH/SUD benefits, and the tool highlights that the Affordable Care Act’s claims procedures include a right of claimants to access the documents detailing the processes, strategies, evidentiary standards and other factors used to apply an NQTL.  

Takeaway

Although third-party administrators and pharmacy benefit managers will do most of the heavy lifting when it comes to plan design, employers who sponsor self-funded health plans that cover MH/SUD should know that any difference between the handling of a MH/SUD benefit and a comparable medical/surgical benefit is a red flag warranting special attention.  For further details, see the final rules, at this link.   

We would like to give a special thanks to Foley Summer Associate Sarah Waste for her contribution to this post. 

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Similar Articles
Relevancy Powered by MondaqAI
 
In association with
Related Topics
 
Similar Articles
Relevancy Powered by MondaqAI
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Mondaq Free Registration
Gain access to Mondaq global archive of over 375,000 articles covering 200 countries with a personalised News Alert and automatic login on this device.
Mondaq News Alert (some suggested topics and region)
Select Topics
Registration (please scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions