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Issues include determining parity within a plan's tiered networks
The long-awaited final rules implementing the Mental Health Parity and Addiction Equity Act (MHPAEA), together with mental health coverage mandates taking effect under the Affordable Care Act (ACA), will result in "the largest expansion of behavioral health care in a generation," said Health and Human Services Secretary Kathleen Sebelius as she announced the release of the final regulations on Nov. 8, 2013.
The rules were published in the Federal Register on Nov. 13, 2013. The HHS Centers for Medicare and Medicaid Services also issued an accompanying set of FAQs on the final rules and a summary analysis.
The MHPAEA requires group health plans to ensure that financial requirements (such as co-pays and deductibles) and treatment limitations (such as caps on doctor visits) that apply to mental-health or substance-abuse benefits are no more restrictive than the limits that insurance plans place on medical or surgical benefits.
The statute applies to plans—both self-insured and fully insured—sponsored by employers with more than 50 employees. The act does not mandate that all plans provide mental-health and substance-abuse benefits, just that they provide parity with medical/surgical benefits if they do. However, under the ACA, "mental health and substance-use disorder services" are considered an "essential health benefit" that nongrandfathered insurance plans in the individual and small-group markets must cover beginning in 2014.
The MHPAEA has had an uneven rollout, with an enforcement safe harbor for those making good-faith efforts to apply its statutory requirements, which took effect for plan years beginning on or after Oct. 3, 2009. Health plan providers also have been guided by interim final rules that the departments of Health and Human Services and Labor issued in February 2010 and that apply to plan years beginning on or after July 1, 2010.
The new regulations are effective on Jan. 13, 2014, except for certain technical amendments effective on Dec. 13, 2013. The mental-health parity provisions of the final rules apply to plan years beginning on or after July 1, 2014. Until the final rules take effect, plans must continue to comply with the parity provisions of the interim final regulations.
Benefit Classifications and Network Tiers
The final rules address a number of unresolved issues, including determining parity between medical and mental-health benefits within a health plan's tiered networks.
The interim final rules established six classifications of benefits and provided that the parity requirements between medical/surgical benefits and mental-health/substance-abuse benefits be applied on a classification-by-classification basis. The six classifications are:
The final regulations maintain these broad classifications and address parity issues regarding subclassifications. For instance, if a plan provides multiple tiers of in-network providers (such as a tier of preferred providers with more generous cost-sharing to participants), the plan may divide its in-network benefits into subclassifications that reflect those network tiers—if the tiering is based on "reasonable factors" and without regard to whether a provider is a mental-health/substance-abuse provider or a medical/surgical provider.
The plan may not impose any financial requirement or quantitative treatment limit on mental-health/substance-abuse benefits in any subclassification that is more restrictive than the predominant financial requirement or quantitative treatment limit that applies to substantially all medical/surgical benefits in the subclassification, the final rules state.
Residential and Outpatient Parity
The final rules require that intermediate levels of mental-health/substance-abuse care be covered equally whether delivered in residential or ‘intensive outpatient’ settings.
“The final regulations, which now provide that ‘parity applies to intermediate levels of care received in residential treatment or intensive outpatient settings,’ are far better than the interim regulations,” commented Jerry Rhodes, chief operating officer of CRC Health Group, a provider of treatment for additiction and other behavioral issues. “HHS did a lot of homework and listened to the field.”
“I am glad they upgraded from the interim rule that excluded a residential level of care,” added Dr. Philip Herschman, CRC's chief clinical officer. “Some major insurance companies had used this to ‘red line’ coverage for much-needed residential addiction treatment.”
The interim final rules contained a clause regarding nonquantitative treatment limitations (plan features that are not expressed numerically but may limit the scope or duration of benefits) that allowed exceptions to the parity requirement for such limits, to be made in accordance with established clinical rationale. However, "the exception clause has been removed from the final rule," said Pamela Greenberg, president of the nonprofit Association for Behavioral Health and Wellness.
"We are disappointed that the exception was taken out, as we believed that there are times when it is clinically appropriate to engage in a level of review that may be different than what is done on the medical side in order to ensure people are receiving the right behavioral health treatment," Greenberg noted.
Among other issues, the final rules also:
High Compliance with Parity Law Found
The results ofan HHS-commissioned study, also released in November 2013, found that large employer-based plans made substantial changes to their benefit designs in response to the MHPAEA's enactment in 2008 and the issuance of the interim final rules in 2010.
The number of plans that applied unequal inpatient day limits, outpatient visit limits or other quantitative treatment limits for mental-health or substance-abuse coverage had dropped significantly by 2011. Differences in cost-sharing for prescription medications and emergency care also declined, and by 2011 practically all large employer-based plans studied appeared to comply with the MHPAEA for those benefits.
However, there was room for improvement, as a minority of large employer-based plans (one in five) in 2011 still required higher co-pays for in-network outpatient mental-health/substance-abuse services than for comparable medical/surgical benefits.
Stephen Miller, CEBS, is an online editor/manager for SHRM.
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