HR LAW: Mental Health Laws
These HR Law: Mental Health Laws are for employers who offer health benefits. All information is sourced from Centers for Medicare and Medicaid Services (CMS.gov) and Department of Labor (DOL.gov).
Mental Health Parity Act of 1996 (MHPA) – provided that large group health plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on medical/surgical benefits.
Mental Health and Addiction Equity Act of 2008 (MHPAEA) The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) generally requires employment-based group health plans and health insurance issuers that provide group health coverage for mental health/substance use disorders to maintain parity between such benefits and their medical/surgical benefits. Specifically, MHPAEA and its implementing regulations generally:
- Provide that financial requirements (such as copays and deductibles), and quantitative treatment limitations (such as visit limits), applicable to mental health or substance use disorder benefits can generally be no more restrictive than the requirements or limitations applied to medical/surgical benefits.
- Include requirements to provide for parity for non-quantitative treatment limitations (such as medical management standards).
- Expand the parity requirements of an earlier law, the Mental Health Parity Act of 1996, such that plans and issuers may not impose a lifetime or annual dollar limit on mental health or substance use disorder benefits that is lower than the lifetime or annual dollar limit imposed on medical/surgical benefits.
Key changes made by MHPAEA, which is generally effective for plan years beginning after October 3, 2009, include the following:
If a group health plan or health insurance coverage includes medical/surgical benefits and MH/SUD benefits, the financial requirements (e.g., deductibles and co-payments) and treatment limitations (e.g., number of visits or days of coverage) that apply to MH/SUD benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits (this is referred to as the “substantially all/predominant test”). This test is discussed in greater detail in the MHPAEA regulation.
MH/SUD benefits may not be subject to any separate cost-sharing requirements or treatment limitations that only apply to such benefits;
If a group health plan or health insurance coverage includes medical/surgical benefits and MH/SUD benefits, and the plan or coverage provides for out-of-network medical/surgical benefits, it must provide for out-of-network MH/SUD benefits; and
Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD benefits must be disclosed upon request.
The Departments of Labor, the Treasury, and Health and Human Services (HHS) (collectively, the Departments), administer MHPAEA together with the States.
Examples of MHPAEA Violations
Insufficient Benefits-Not offering out-of-network providers or inpatient benefits to treat mental health or substance use disorders even though these benefits are available for medical/surgical benefits.
Higher Financial Requirements-Charging higher copays to see mental health providers than those charged for medical/surgical providers.
More Restrictive Quantitative Treatment Limitations (QTLs)-Imposing visit limits on mental health benefits that are more restrictive than those applied to medical/surgical visits.
More Restrictive Non-Quantitative Treatment Limitations (NQTLs)-Imposing broad pre-authorization requirements on all mental health and substance use disorder treatments, even though these same plans only required pre-authorization on a select few medical/surgical treatments. -Requiring written treatment plans for mental health services while not requiring similar plans to receive medical/surgical treatment.
Lower Annual Dollar Limits on Benefits-Imposing annual dollar limits on coverage of mental health benefits when such limitations are not imposed on medical/surgical benefits.
Inadequate Disclosures-Not disclosing the criteria used for determining medical necessity and/or reasons for benefit denials. HR Law: Mental Health Laws
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