Recent­ly, the Depart­ment of the Trea­sury, Depart­ment of Labor (DOL), and Depart­ment of Health and Human Ser­vices (HHS) (col­lec­tive­ly, the Depart­ments) issued FAQs About Afford­able Care Act Imple­men­ta­tion Part 34 and Men­tal Health and Sub­stance Use Dis­or­der Par­i­ty Imple­men­ta­tion.

The Depart­ments’ FAQs cov­er two pri­ma­ry top­ics: tobac­co ces­sa­tion cov­er­age and men­tal health / sub­stance use dis­or­der parity.

Tobac­co Ces­sa­tion Coverage

The Depart­ments seek pub­lic com­ment by Jan­u­ary 3, 2017, on tobac­co ces­sa­tion cov­er­age. The Depart­ments intend to clar­i­fy the items and ser­vices that must be pro­vid­ed with­out cost shar­ing to com­ply with the Unit­ed States Pre­ven­tive Ser­vices Task Force’s updat­ed tobac­co ces­sa­tion inter­ven­tions rec­om­men­da­tion applic­a­ble to plan years or pol­i­cy years begin­ning on or after Sep­tem­ber 22, 2016.

Men­tal Health / Sub­stance Use Dis­or­der Parity

Gen­er­al­ly, the Men­tal Health Par­i­ty and Addic­tion Equi­ty Act of 2008 (MHPAEA) requires that the finan­cial require­ments and treat­ment lim­i­ta­tions imposed on men­tal health and sub­stance use dis­or­der (MH/SUD) ben­e­fits can­not be more restric­tive than the pre­dom­i­nant finan­cial require­ments and treat­ment lim­i­ta­tions that apply to sub­stan­tial­ly all med­ical and sur­gi­cal benefits.

A finan­cial require­ment (such as a copay­ment or coin­sur­ance) or quan­ti­ta­tive treat­ment lim­i­ta­tion (such as a day or vis­it lim­it) is con­sid­ered to apply to sub­stan­tial­ly all medical/surgical ben­e­fits in a clas­si­fi­ca­tion if it applies to at least two-thirds of all medical/surgical ben­e­fits in the classification.

If it does not apply to at least two-thirds of medical/surgical ben­e­fits, it can­not be applied to MH/SUD ben­e­fits in that classification.

If it does apply to at least two-thirds of medical/surgical ben­e­fits, the lev­el (such as 80 per­cent or 70 per­cent coin­sur­ance) of the quan­ti­ta­tive lim­it that may be applied to MH/SUD ben­e­fits in a clas­si­fi­ca­tion may not be more restric­tive than the pre­dom­i­nant lev­el that applies to medical/surgical ben­e­fits (defined as the lev­el that applies to more than one-half of medical/surgical ben­e­fits sub­ject to the lim­i­ta­tion in the classification).

In per­form­ing these cal­cu­la­tions, the deter­mi­na­tion of the por­tion of medical/surgical ben­e­fits sub­ject to the quan­ti­ta­tive lim­it is based on the dol­lar amount of all plan pay­ments for medical/surgical ben­e­fits in the clas­si­fi­ca­tion expect­ed to be paid under the plan for the plan year. The MHPAEA reg­u­la­tions pro­vide that “any rea­son­able method” may be used to deter­mine the dol­lar amount of all plan pay­ments for the sub­stan­tial­ly all and pre­dom­i­nant analyses.

MHPAEA’s pro­vi­sions and its reg­u­la­tions express­ly pro­vide that a plan or issuer must dis­close the cri­te­ria for med­ical neces­si­ty deter­mi­na­tions with respect to MH/SUD ben­e­fits to any cur­rent or poten­tial par­tic­i­pant, ben­e­fi­cia­ry, or con­tract­ing provider upon request and the rea­son for any denial of reim­burse­ment or pay­ment for ser­vices with respect to MH/SUD ben­e­fits to the par­tic­i­pant or beneficiary.

How­ev­er, the Depart­ments rec­og­nize that addi­tion­al infor­ma­tion regard­ing medical/surgical ben­e­fits is nec­es­sary to per­form the required MHPAEA analy­ses. Accord­ing to the FAQs, the Depart­ment have con­tin­ued to receive ques­tions regard­ing dis­clo­sures relat­ed to the process­es, strate­gies, evi­den­tiary stan­dards, and oth­er fac­tors used to apply a non­quan­ti­ta­tive treat­ment lim­i­ta­tion (NQTL) with respect to medical/surgical ben­e­fits and MH/SUD ben­e­fits under a plan. Also, the Depart­ments have received requests to explore ways to encour­age uni­for­mi­ty among state reviews of issuers’ com­pli­ance with the NQTL stan­dards, includ­ing the use of mod­el forms to report NQTL information.

To address these issues, the Depart­ments seek pub­lic com­ment by Jan­u­ary 3, 2017, on poten­tial mod­el forms that could be used by par­tic­i­pants and their rep­re­sen­ta­tives to request infor­ma­tion on var­i­ous NQTLs. The Depart­ments also seek pub­lic com­ment on the dis­clo­sure process for MH/SUD ben­e­fits and on steps that could improve state mar­ket con­duct exam­i­na­tions or fed­er­al over­sight of com­pli­ance by plans and issuers, or both.

 

By Danielle Capil­la, Orig­i­nal­ly pub­lished by Unit­ed Ben­e­fit Advi­sors — Read More