The Employee Benefits Security Administration (the “EBSA”) has issued FAQs, which provide guidance on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (the “Mental Health Parity Act” or “MHPA”), as applicable to group health plans (among others).
According to the FAQs, the MHPA specifies that the financial requirements and treatment limitations imposed by a group health plan on mental health and substance use disorder benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical and surgical benefits. The MHPA also prohibits the plan from imposing financial requirements or treatment limitations that are applicable only to mental health or substance use disorder benefits.
Under regulations issued under the MHPA, a group health plan generally cannot impose a financial requirement (such as a copayment or coinsurance) or a quantitative treatment limitation (such as a limit on the number of outpatient visits or inpatient days covered) on mental health or substance use disorder benefits in any of 6 classifications that is more restrictive than the financial requirements or quantitative treatment limitations that apply to at least 2/3 of medical/surgical benefits in the same classification. Thus, if the plan generally applies a $25 copayment to at least 2/3 of outpatient, in-network, medical/surgical benefits, a higher copayment could not be imposed on outpatient, in-network mental health or substance use disorder benefits.
Further, group health plans often impose nonquantitative treatment limitations, such as:
–medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether a treatment is experimental or investigative;
–standards for provider admission to participate in a network, including reimbursement rates; and
–methods used to determine usual, customary, and reasonable fee charges.
The MHPA regulations provide that, under the terms of the plan as written and in practice, any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation with respect 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 with respect to medical/surgical benefits. However, differences are permitted when there are recognized clinically appropriate standards of care.
The FAQs then apply the above rules to situations involving prior authorizations for benefits and other matters. For example, the FAQs clarify that the plan cannot require prior authorization as to the medical necessity of receiving mental health and substance abuse disorder benefits, if it does not require such prior authorization for medical/surgical benefits.