The Centers for Medicare & Medicaid Services (“CMS”) has issued FAQs on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 ( the “MHPAEA”), as amended by the Affordable Care Act. These FAQs are intended to be read in conjunction with the final regulations on the MHPAEA, issued November 8, 2013.
CMS says that the MHPAEA amended the Public Health Service Act (“PHS Act”), ERISA and the Internal Revenue Code (the “Code”) to provide increased parity between mental health and substance use disorder benefits and medical/surgical benefits offered by , among others, group health care plans. In general, MHPAEA requires that the financial requirements (such as coinsurance) and treatment limitations (such as visit limits) imposed 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/surgical benefits. The FAQs say the following:
–MHPAEA’s statutory provisions generally became effective for plan years beginning after October 3, 2009. The final regulations generally apply to group health care plans and health insurance issuers offering group health insurance coverage for plan years beginning on or after July 1, 2014. Until the applicability date of the final rules, plans and issuers subject to MHPAEA must continue to comply with the earlier interim rules.
–The earlier interim rules had contained an exception for differences in nonquantitative treatment limitations between medical/surgical benefits and mental health or substance use disorder benefits based on “clinically appropriate standards of care.” The final regulations eliminate this exception.
— The final regulations apply parity requirements to benefits for intermediate levels of care for mental health conditions and substance use disorders.
–Under the final regulations, parity requirements for nonquantitative treatment limitations also apply to restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services (including access to intermediate level services).
–The final regulations clarify the disclosure rights of plan participants with respect to both mental health and substance use disorder benefits and medical/surgical benefits. FAQ 8 describes certain information which a participant may obtain from the health plan.
— The final regulations establish standards and procedures for claiming an increased cost exemption under MHPAEA.