A few months ago, the Department of Labor released a fact sheet on the efforts of the Employee Benefits Security Administration (EBSA) and the Centers for Medicare and Medicaid Services (CMS) to enforce the Mental Health Parity and Addiction Equity Act (MHPAEA).
MHPAEA, commonly referred to as the federal parity law, is widely considered to be one of the most seminal statutes as it relates to advancing care for individuals with mental health and substance use disorder (MH/SUD) needs.
At its core, this is an anti-discrimination law meant to ensure that individuals have access to behavioral health services, in a comparable fashion to medical and surgical services.
What is the purpose of this enforcement fact sheet?
EBSA has been summarizing its enforcement activities since 2016 with fiscal year 2015 data. CMS released their first report in late 2017 which was a compilation of investigations completed in 2016 and 2017.
This is the first time EBSA and CMS have combined their findings in one document to give a more complete picture of efforts the federal government has taken to combat MHPAEA violations.
EBSA investigated violations in the following categories:
- Annual dollar limits
- Aggregate lifetime dollar limits
- Benefit classifications
- Financial requirements
- Treatment limitations
- Cumulative financial requirements and quantitative treatment limitations (QTLs)
- Claims processing
- Disclosure violations
While the number of investigations declined from FY2018, the majority of violations cited were pertaining to QTLs and non-quantitative treatment limitations (NQTLs).
One example of an NQTL that was cited was a more stringent approach to medical necessity reviews for outpatient behavioral health treatment. Under this example, some plans imposed this NQTL on outpatient behavioral health services after 30 visits but allowed up to 52 visits of a comparable medical/surgical benefit.
As such, the plans now must allow up to 52 outpatient behavioral health visits in a 12-month period prior to implementing any medical necessity review requirement. In addition, the plans had to repay almost $20,000 as a result of readjusted claims.
Other common potential QTL and NQTL parity violations are:
- Higher coinsurance for outpatient mental health treatment than other medical benefit
- Limit on number of inpatient SUD treatment facility days
- Prior authorization requirements for behavioral health benefit and not medical benefit
- Step therapy requirements for depression medication and not high blood pressure medication
- Higher prescription copay for behavioral health treatment than comparable medical treatment
Keeping Your Organization In Compliance
It’s important for plans, their benefit administrators, employers, and consumers to be able to spot a potential parity violation easily. A recent report from the Government Accountability Office indicates that there are varying approaches to enforcement from federal and state governments.
While they both conduct reviews to assess parity compliance, in general, they do not occur with any regular frequency and vary in scope. As such, it is important for plans to always be prepared, for both review purposes and to comply with both the spirit and letter of the requirements.
To register for our FREE Mental Health Parity Webinar on Tuesday, June 30, 3:00pm, click here
To learn more about URAC’s Parity Program and how it can help your organization mitigate compliance concerns, click here.