GHC 821-18: Employer Guide for Compliance with Mental Health Parity and Addiction Equity Act Flashcards
Background
- Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) – 2008
a. Requires group health plans, health insurance issuers, and individual health plans to have parity (equality) between mental health and substance use disorder (MH/SUD) benefits and medical/surgical benefits
b. Parity with respect to financial requirements and treatment limitations
c. Penalties for noncompliance
- Guide prepared by Milliman
Introduction and Purpose
1. MHPAEA
a. Prohibits imposing financial requirements on MH/SUD benefits that are more restrictive than for medical/surgical benefits
b. Prohibits separate financial requirements for MH/SUD benefits
c. Effective as of Oct. 2009 (passed in Oct. 2008)
d. Penalties as high as $100 per member per day of noncompliance
2. Final Rules
a. Nov. 2013 – document published by Dept. of Labor, Dept. of Treasury and Dept. of Health and Human Services
b. Clarifications and guidance of MHPAEA
- How to perform testing of nonquantitative treatment limitations (NQTL)
- Disclosure of plan information
- Testing of tiered networks
- Scope of services
c. Implement provisions for individual coverage and non-GF plans in individual and small group markets
- Prior to ACA, MHPAEA applied to group health plans
3. FAQs
a. Issued by DOL’s Employee Benefits Security Administration (EBSA)
b. Questions about implementation and interpretation
c. EBSA also issued Self-Compliance Tool – for use with ERISA and HIPAA compliance
- URAC (Utilization Review Accreditation Committee) compliance standards
a. Health plans must document their basis for compliance
b. Other disclosure standards - Employer is liable for noncompliance, so this document provides advice and should be used as a guide and supplement
- Parity tests are not safe harbor situations (don’t automatically pass due to certain results), as the tests depend on facts and circumstances
- Guide provides series of questions for compliance
a. Can be used by employers and also state agencies for review of compliance
b. Not a substitute for legal advice - Detailed, written records of compliance should be kept
- Reevaluate compliance when there are changes to plan design, cost-sharing or utilization
Part 1: Determining Classifications of Benefits and Coverage Requirements (Including Scope of Service Considerations)
- Final Rules provide specific rules for determining benefit classifications to help determine coverage requirements and apply parity standards
- Compare benefits offered (MH/SUD vs medical/surgical) in each of the benefit classifications and sub-classifications
1. Classification of Benefits
a. Plans can vary benefits based on type of treatment facility (inpatient, outpatient), plan’s network and for prescription drugs
- Classifications of Benefits for MH/SUD Parity
(1) Inpatient, In-Network (IP, IN)
(2) Inpatient, Out-of-Network (IP, OON)
(3) Outpatient, In-Network (OP, IN)
(4) Outpatient, Out-of-Network (OP, OON)
(5) Emergency Care
(6) Prescription Drugs
b. Parity requirements applied in each classification
c. Definitions of classifications must be uniform for MH/SUD and medical/surgical
d. Scope of services to be covered not defined in Final Rules, but must be consistent
- No requirement to provide any particular service, but if plan provides MH/SUD benefits, then it must offer comparable MH/SUD benefits to the medical/surgical benefits
e. Comparability of facility types and levels of care also required
f. If no provider network, all benefits are considered OON
2. Medical/Surgical vs. MH/SUD Benefits
a. Determination of medical/surgical vs. MH/SUD depends on definitions (under terms of plan and in accordance with federal and state laws)
- Consistent with standards of medical practice (ICD and DSM classifications)
- Prevent health plan from changing definitions to avoid parity tests
3. Permissible Sub-classifications
(1) Multi-tiered Prescription Drug Benefits
* Drug benefits have different financial requirements for different tiers based on reasonable factors
- Can’t take into consideration whether drug is generally prescribed for medical/surgical vs. MH/SUD
- Consider cost, efficacy, generic vs. brand, mail order vs. pick-up
(2) Multiple Network Tiers
* Plans may have two or more network tiers (e.g. preferred provider, participating provider)
- Important for controlling costs and managing quality of care
* Tiering must be based on reasonable factors without regard to whether providers are providing medical/surgical vs. MH/SUD
(3) Office Visits (Separate from Other Outpatient Services)
* Plans may have different provisions for office visits vs. other types of OP services
- E.g. $25 copay for office visits and 20% coinsurance for OP surgery
- May not create sub-classifications for generalist and specialists
4. Benefits Coverage / Scope of Services
a. Meet requirements if all MH/SUD benefits are at least as rich as the richest medical/surgical benefit in each classification
b. Guaranteed to pass by providing 100% benefit coverage without limits for all MH/SUD benefits in each classification
c.MHPAEA does NOT require plans to provide any MH/SUD benefits
- IF MH/SUD benefits are provided in one classification, must also provide MH/SUD benefits in other classifications if corresponding medical/surgical benefits exist
d. No official scope of services
- Geographic location, facility type, provider specialty and other criteria that limit benefit – these are illustrations of nonquantitative treatment limitations and must comply with parity tests
- Questions for Analysis of Classifications, Benefits Coverage and Scope
(1) How plan determines types and levels of service for MH/SUD for each classification?
(2) How benefits are determined to be provided for covered MH/SUD in each classification?
(3) Any differences in MH/SUD definitions of levels of care compared to medical/surgical?
(4) If they have different types of IP, non-hospital setting coverage for medical/surgical (sub-acute,
etc), do they have it for MH/SUD?
(5) Any treatment types offered for medical/surgical but excluded for MH/SUD (e.g. diagnostic lab
tests)?
(6) Does plan offer specialty medical/surgical hospitals but exclude MH/SUD specialty IP
programs?
(7) If emergency benefits vary IN and OON, how was this handled for compliance testing?
(8) Do final benefits determinations for each class fit with parity test for nonquantitative treatment
limitations?
Part 2: Complying with Parity Standards Regarding Financial Requirements and Quantitative Treatment Limitations
Parity requirements
A) Financial requirement for MH/SUD benefits that is more restrictive than predominant financial treatment for substantially all medical/surgical benefits in same classification is prohibited
B) Separate financial requirements only for MH/SUD benefits are prohibited
o E.g. first determine if quantitative treatment limitations (QTLs) apply only to MH/SUD benefits. If so, plan fails. If not, then determine if plan meets “predominant” and “substantially all” tests
1. Key Terms
a. Financial Requirements, QTLs, NQTLs
- Financial requirements – outline cost sharing
- Treatment limitations – quantitative or nonquantitative (QTL or NQTL)
* QTL – expressed numerically (e.g. calendar yr. limits, number of office visits, etc)
b. Type
- Financial requirements and treatment limitations of the same nature
* E.g. Copays, coinsurance, annual visits
* Items of the same type can only be compared to items of that specific type (e.g. copays to copays)
c. Level
- Magnitude of financial requirement ($, percentage, number of days, visit amount)
d. Coverage Unit
- Way in which plan groups individuals for purpose of determining premiums, benefits or contributions
2. Measuring Plan Benefits
a. Each financial requirement within a coverage unit must be analyzed separately within each classification
b. Portion of plan payments subject to financial requirements is based on dollar amount of all plan payments for medical/surgical benefits in classification that are expected to be paid under the plan for the year
c. Plan benefits – based on allowed amounts (before cost sharing)
d. Key questions regarding benefit classification requirements:
(1) Was plan tested at coverage level unit (EE only, EE plus spouse, Family, etc)?
(2) How were benefit costs divided into the six classifications?
(3) Were costs considered on allowed cost basis or paid cost basis?
(4) Were costs developed for each classification in total or for different service categories in each?
(5) What % of medical/surgical benefits within each classification are subject to each type of financial requirement?
(6) How was different cost sharing within subset of in-network benefits handled and were permissible sub-classifications used?
3. Applying General Parity Rule for Financial Requirements and QTLs
a. First – split benefits into classifications and determine if financial requirement or QTL applies only to MH/SUD benefits
- If so, plan violates MHPAEA
b. Second – if requirement/QTL applies to both medical/surgical and MH/SUD, determine if it
applies to “substantially all” of medical/surgical benefits in same classification
- Substantially all – applies to at least 2/3 of all benefits in that classification (based on dollar amount of plan payments for the year)
- [Refers to what percentage of the group is affected]
c. Third – if it applies to substantially all, then apply the “predominant” test
- Predominant – level of the requirement that applies to more than half of the medical/surgical benefits in that classification
- [Refers to the amount of the average financial requirement, for the group that is affected]
- If a single level applies to more than half the medical/surgical benefits, it is predominant
* Financial requirements for MH/SUD cannot be more restrictive than that
- If no one level applies to more than half the medical/surgical benefits, combine the levels until the combination of levels equals more than half of the benefits (start combining from the most restrictive levels and move down)
* Financial requirements for MH/SUD cannot be more restrictive than the lowest level in the combination
Example #3
i. EE only: $250 deductible on all medical/surgical benefits
ii. Family: $500 deductible on all medical/surgical benefits
iii. All groups: 20% coinsurance for all medical/surgical benefits
iv. No provider network (for testing, all benefits are consider Out-of-Network)
v. Substantially All test – look at EE only and Family groups separately
- EE only - $250 deductible
* MH/SUD benefits for EE only could not be more restrictive than this
- Family - $500 deductible
* MH/SUD benefits for Family could not be more restrictive than this
vi. Predominant Level test – coinsurance applies to all benefits, so do not need to split by EE only and Family, so predominant level is 20% coinsurance
d. MH/SUD providers often considered specialists by health plans
- Different level of copay/coinsurance
- Sometimes should be considered primary, sometimes specialist
e. Questions to consider about compliance testing for QTLs
(1) Any financial requirements that apply to MH/SUD and not medical/surgical?
(2) Describe financial model used to test compliance – claims data, calendar period, level of detail for benefit and service categories
(3) What percentages in each classification are subject to financial requirements and have benefits been fixed to make sure it did it pass “substantially all” testing?
(4) How were single copays that apply to all services in an office visit treated in testing?
(5) What is the “predominant” level for “substantially all” in each classification of testing? o 6. Does cost sharing for pharmacy benefits vary based on whether drug is medical/surgical vs MH/SUD condition?
Cumulative Financial Requirements and QTLs
- Plan cannot apply cumulative financial requirements that accumulate separately for MH/SUD and medical/surgical
- E.g. deductibles, OOP max, visit limits - Key questions regarding separately accumulating financial requirements
(1) Have financial requirements been aggregated so medical/surgical and MH/SUD satisfy
the same financial requirement?
(2) If plan has separate accumulating requirements, what technological system changes
were made to ensure integrated accumulation on a timely basis?
Aggregate Lifetime and Annual Dollar Limits
- Plan must comply with general parity rules for aggregate lifetime and annual dollar limits
a. Only applies to MH/SUD benefits that are NOT subject to EHB requirements of ACA - (ACA prohibits annual and lifetime limits on EHBs, including behavioral health)
a. For plans not covered by ACA – key question
(1) Have annual dollar limits been removed from all MH/SUD benefits or matched to comparable medical/surgical limits by classification?
