The FAQs about Affordable Care Act Implementation Part 31 released on April 20, 2016 mark the fourth time the Mental Health Parity and Addiction Equity Act (MHPAEA) disclosure rules have been addressed by the Department of Labor (DOL) in its series of answers to questions from stakeholders.
MHPAEA provides increased parity between mental health and substance use disorder (MH/SUD) benefits and medical/surgical benefits. MHPAEA requires that the financial obligations (such as coinsurance and copays) and treatment limitations (such as visit limits and utilization management techniques) imposed on MH/SUD benefits cannot be more restrictive than the predominant financial obligations and treatment limitations that apply to substantially all medical/surgical benefits.
Nonquantitative treatment limitations (NQTLs) such as medical management standards for medical necessity may not be more stringent for MH/SUD benefits than they are for comparable medical/surgical benefits. MHPAEA rules impose specific disclosure requirements on plan administrators and health insurance issuers. Medical necessity criteria for both MH/SUD benefits and medical/surgical benefits, as well as any processes, strategies, evidentiary standards, or other factors used in developing the underlying NQTL and in applying it, must be disclosed to any current or potential participant, beneficiary, or contracting provider upon request.
Two more disclosure issues were clarified in the most recent FAQs.
- A potential plan participant/enrollee is able to request a copy of the medical necessity criteria.
- The items that a plan must disclose to a provider acting as an authorized representative for an ERISA group health plan participant, upon request, include:
- A Summary Plan Description (SPD) from an ERISA plan, or similar summary information that may be provided by non-ERISA plans;
- The specific plan language regarding the imposition of the NQTL (such as a preauthorization requirement);
- The specific underlying processes, strategies, evidentiary standards, and other factors (including, but not limited to, all evidence) considered by the plan (including factors that were relied upon and were rejected) in determining that the NQTL will apply to this particular MH/SUD benefit;
- Information regarding the application of the NQTL to any medical/surgical benefits within the benefit classification at issue;
- The specific underlying processes, strategies, evidentiary standards, and other factors (including, but not limited to, all evidence) considered by the plan (including factors that were relied upon and were rejected) in determining the extent to which the NQTL will apply to any medical/surgical benefits within the benefit classification at issue; and
- Any analyses performed by the plan as to how the NQTL complies with MHPAEA.
FAQs Part 29 clarify that plan administrators and health insurance issuers cannot deny requests for documents by asserting the information is “proprietary” and/or has “commercial value,” even in cases where the source of the information is a third-party commercial vendor.
Plans may provide a summary description of the medical necessity criteria in layperson’s terms, but a summary is not required. If the actual medical necessity criteria are requested, then providing a summary is not an appropriate substitute.
According to FAQs Part 5 Question 10, under ERISA, documents with information on the medical necessity criteria for both medical/surgical benefits and mental health/substance use disorder benefits are plan documents, and copies of plan documents must be furnished within 30 days of request.
FAQs Part 17 Question 8 addressed disclosure for claim denials and appeals under MHPAEA.
- The reason for any denial of reimbursement or payment for services for MH/SUD benefits must be made available to participants and beneficiaries.
- Under the internal appeals and external review requirements added by the Affordable Care Act, non-grandfathered group health plans and health insurers must provide to a participant (or a provider or other individual acting as a patient’s authorized representative), upon request and free of charge, all documents and information relevant to the claim for benefits as well as the processes, strategies, evidentiary standards, and other factors used to apply a NQTL. The plan or insurer must provide the claimant with any new or additional evidence considered, relied upon, or generated in connection with a claim.
- When a plan administrator makes an adverse benefit determination upon review based on a new or additional rationale, the claimant must be provided, free of charge, with the rationale.
If you’re interested in checking your plan’s compliance status, see DOL’s Warning Signs – NQTLs that Require Additional Analysis to Determine Mental Health Parity Compliance. Milliman and the Partnership for Workplace Mental Health Employer Guide for Compliance with MHPAEA highlights key questions related to compliance testing of NQTLs and medical necessity criteria in Part 3.
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Jenny Lucey, CEBS
Information/Research Specialist at the International Foundation