The Department of Labor (DOL) Employee Benefits Security Administration (EBSA)’s 2024 Mental Health Parity and Addiction Equity Act (MHPAEA) report to Congress, issued January 17, 2025, addressed the enforcement approach to nonquantitative treatment limitations (NQTLs) for network adequacy and network composition.
The report included a settlement agreement resulting from an EBSA investigation of the NQTL “standards for provider admission to participate in a network including reimbursement rates, for in-network inpatient and in-network outpatient services.” The settlement agreement exemplifies how plans, through their insurance network administrators, can monitor network adequacy standards and address network gaps. Data lists provide examples of how a plan can show that it uses the same or comparable standards to evaluate the adequacy of M/S and MH/SUD networks.
During an 18-month monitoring period, on a quarterly basis, the fund will evaluate the comparative adequacy of its “Network Administrator’s Network” as applied to M/S and MH/SUD providers.
In each quarterly review, the fund will collect and evaluate certain data and measurements to identify network gaps using six tables/lists of data elements plus another list on telehealth utilization. Table 1 was covered in Part I.
What’s new: This blog (Part II) will cover the tables in the settlement agreement showing the negotiated corrections for the fund to identify network gaps regarding network providers, wait times, travel time or distance, provider to member ratios, and telehealth for mental health/substance use disorder (MH/SUD) services as compared to medical/surgical (M/S) services (Tables 2-6). Table 2 has designated categories of MH/SUD and M/S providers. Tables 3-6 use a separate list of provider categories.
The tables have notes on methodology as well as what the fund will request from the network administrator, which are not included here. The data lists are to give you an idea of what data points and provider categories plans can track.
Highlights from section II. A. “Measurement and Improvement of the Network Administrator’s Network” of the Settlement Agreement
Notes: The sample tables of data start on page 138 of the report. These measurements may be based on the network administrator’s book of business, as opposed to the fund-specific data, presuming the book of business is representative of the fund’s experience.
Table 2: Network Providers Actively Submitting Claims Data to Report
For each of the bullet points, break out in-person providers vs. telehealth providers.
- Total number of network providers (do not include single case agreement providers)
- Total number (and %) of network providers noted as accepting new patients in directory
- Total number (and %) of network providers who have submitted no network claims in the last six months
- Total number (and %) of network providers who have submitted network claims for one to four unique participants/beneficiaries (P/Bs) in the last six months
- Total number (and %) of network providers who have submitted network claims for five or more unique P/Bs in the last six months
Table 2 Provider Categories
Note: Categories to use in breaking out Table 2 numbers should include the following providers, in addition to all provider types the plan or network has identified as “high volume” or “high impact.”
- MH/SUD
- Psychiatrists (not including child/adolescent psychiatrists)
- Psychologists (not including child/adolescent psychologists)
- Child/adolescent psychiatrists
- Child/adolescent psychologists
- Master’s-level MH providers (counselors, marriage and family therapists, independent clinical social workers, advanced social workers)
- Non-master’s-level MH providers
- Board-certified SUD addiction medicine physicians
- Other non-physician SUD professionals
- Medical/Surgical
- PCP/family practice (not including pediatricians)
- Pediatrician
- OB/GYN
- Cardiologists
- Neurologists
- All other specialty physicians (not otherwise listed)
- Non-physician primary care providers
- Non-physician specialty providers
Table 3: Wait Times for New and Existing Patients Data to Report (based on participant/patient surveys)
- Median wait time for new patient appointment
- Mean wait time for new patient appointment
- Median wait time for returning patient appointment
- Mean wait time for returning patient appointment
Table 3 Providers Categories
Notes: Tables 3-6 use the same categories. Table 3 adds facility categories that Table 2 doesn’t have.
Categories to use in breaking out Table 3 numbers should include the following providers, in addition to all provider types the plan or network has identified as “high volume” or “high impact.”
- MH/SUD
- Psychiatrists (not including child/adolescent psychiatrists)
- Psychologists (not including child/adolescent psychologists)
- Child/adolescent psychiatrists
- Child/adolescent psychologists
- Master’s-level MH providers (counselors, marriage and family therapists, independent clinical social workers, advanced social workers)
- Non-master’s-level MH providers
- Board-certified SUD addiction medicine physicians
- Other non-physician SUD professionals
- MH acute facility
- MH subacute facility (such as partial hospitalization program (PHP), residential)
- MH child/adolescent facility (of any level of care)
- SUD acute facility
- SUD subacute facility
- Medical/Surgical
- Primary Care Provider (PCP)/family practice (not including pediatricians)
- Pediatrician
- OB/GYN
- Cardiologists
- Neurologists
- All other specialty physicians (not otherwise listed)
- Non-physician primary care providers
- Non-physician specialty providers
- Acute facility
- Subacute facility
- Child/adolescent facility (any level of care)
Table 4: Time & Distance Measurements Data to Report
- Time/distance metrics for each provider category by county type: large metro, metro, micro, rural, and Counties with Extreme Access Considerations (CEAC).
- Number and percent of these types of counties that meet time/distance standards. When assessing the number and percent of these types of counties that meet time/distance standards, BNF must count only providers and facilities who actively submitted one or more claims in the last six months.
Table 5: Provider-To-Member Ratios Data to Report
- Target ratios by category
- Actual ratios by category—When calculating actual ratios by category, BNF must count only providers and facilities who actively submitted one or more claims in the last six months.
Table 6: Network Retention/Loss Analysis Data to Report
- Number of providers who were part of the network but left the network in the last two years
- Number of prospective providers who engaged in application process and/or negotiation to join the network, but ultimately did not join the network
- Reason for leaving or not joining the network
Telehealth Utilization. Quarterly monitoring of the following aspects of telehealth utilization.
- Average wait times for appointments
- Gaps in telehealth network
- Member complaints
Working With the Insurance Network Administrator
DOL’s 2024 report to Congress addressed the enforcement approach to nonquantitative treatment limitations (NQTLs) for network adequacy and network composition. The settlement agreement provides examples of how plans, through their insurance network administrators, can show that they use the same or comparable standards to evaluate the adequacy of M/S and MH/SUD networks. See Part I for data lists regarding out-of-network utilization tracking. If a network administrator fails to timely provide the requested information to the multiemployer fund or plan sponsor, the fund is expected to notify EBSA so that EBSA can take appropriate action.
Developed by International Foundation Information Center staff. This does not constitute legal advice. Please consult your plan professionals for legal advice.
