Despite passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) over a decade ago, access to behavioral health and substance use disorder services continues to be an issue of wide debate.
As new treatments are developed and/or recognized, the healthcare industry must wrestle with MHPAEA’s requirements for coverage parity. This is the case with autism spectrum disorder.
The dramatic increase in autism diagnoses in the past decade has seen a greater demand for treatment, which requires health plans, patients, parents, and advocates to grapple with the impact of MHPAEA. If you’re not familiar with MHPAEA, this article provides a summary of the law’s relevance to autism treatment.
Background: The Mental Health Parity and Addiction Equity Act
MHPAEA is a federal law that prohibits insurers, health plans, issuers, and managed care organizations from imposing limits on mental health and substance use disorder (MH/SUD) benefits that are more restrictive than those imposed for medical/surgical benefits in the same classification (e.g., outpatient, inpatient, etc.).
The limits are identified as quantitative treatment limits (QTLs) and nonquantitative treatment limits (NQTLs). While QTLs are fairly easy to recognize (e.g., visit limits, copays, etc.), NQTLs are not as readily identifiable. The Departments of Health and Human Services, Labor, and Treasury collectively issued guidance titled, , to help identify plan and policy limits that should “trigger careful analysis” to ensure the product is MHPAEA compliant.
What are Non-Quantitative Treatment Limits (NQTLs)?
NQTLs manifest themselves in a variety of health plan provisions, including those that address treatment plans, in-network provider requirements, preauthorization and reauthorization requirements, and restrictions on location or facility type, to name a few.
What is Autism Spectrum Disorder (ASD)?
According to the National Institute of Mental Health, is a developmental disorder that affects communication and behavior. Although autism can be diagnosed at any age, it is said to be a “developmental disorder” because symptoms generally appear in the first two years of life.
NQTLs and the Treatment of Autism Spectrum Disorder
The treatment of ASD is relatively new when compared to long-standing medical treatments. While MHPAEA is clear about its parity requirements, health plans, providers, and patients continue to encounter friction points related to ASD treatment. Many elements that routinely comprise evidence-based autism treatment (e.g., treatment goals, data collection, parent/caregiver participation, etc.) may inadvertently find their way into payer guidelines and prior authorization criteria.
Three common areas of friction related to ASD treatment are:
- Pre-Authorization Requirements: As MPHAEA makes clear, pre-authorization requirements for ASD treatment should not be different or more burdensome than pre-authorization requirements for substantially all medical and surgical services in the same classification (i.e., in-network outpatient or out-of-network outpatient). The sub-regulatory guidance referenced above explicitly identifies pre-authorization requirements as an example of an NQTL for which health plans should consider additional analysis to ensure compliance with MHPAEA given the unique requirements of treatment.
- Treatment Plans: Treatment plans are often critical to utilization review and efforts to identify fraud. While treatment plans are often not required as a condition of authorization for treatment, some health plans require treatment plans prior to the approval of ASD treatment. MPHAEA’s clear parity rules have led some to question the appropriateness of such requirements for ASD treatment. It is important that health plans analyze their utilization review protocols for compliance with MPHAEA’s parity requirements.
- Parent/Caregiver Participation: Many autism treatment programs encourage or even require parent/caregiver participation to optimize treatment outcomes. Health plans routinely reimburse providers for training caregivers to participate effectively in the treatment of their loved one. However, the NQTL rules appear to limit a health plan’s ability to consider a caregiver’s participation as a criterion for authorization of treatment – unless that same variable is taken into account in determining the medical necessity of all other benefits in the same classification (i.e., in-network outpatient or out-of-network outpatient).
Despite its enactment over a decade ago, mental health parity continues to be a complex issue that may warrant additional training, scrutiny, and/or review. As access to mental health services expands and some diagnoses, such as ASD, increase in prevalence, current and emerging health plan guidelines and policies should be viewed through the lens of MHPAEA’s strict prohibition on quantitative and non-quantitative treatment limits.
URAC’s Health Plan Accreditation includes standards addressing mental health parity to conform with the adoption of the bipartisan Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act.
URAC will continue its efforts to convene and engage stakeholders to ensure that payers, patients, and their advocates continue to work together to ensure everyone has access to appropriate and timely medically necessary care. .
This article was co-written by Julie Kornack, director of public policy, Aaron Turner-Phifer, vice president, government relations and policy, URAC.