Compliance News | November 5, 2020

Departments Publish Mental Health Parity Compliance Tool

Enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) continues and has been highlighted as a federal priority in recent reports released by the DOL and HHS. Recently, those departments published the final version of a tool that is intended to help plan sponsors self-evaluate their compliance with MHPAEA.

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The tool particularly focuses on the parity rules related to nonquantitative treatment limitations (NQTLs). NQTLs refer to benefit-management techniques such as prior-authorization requirements, determinations that a treatment is experimental, methods for reimbursing providers, step-therapy protocols and restrictions based on geographic location or facility type.

Notably, the additions to the tool include:

  • Best practices for establishing an internal compliance plan
  • Revised and additional examples, particularly related to application of MHPAEA’s NQTL rules and in response the 21st Century Cures Act
  • Additional “warning signs” — plan terms that do not on their own signify a MHPAEA violation, but raise a red flag that a treatment limitation may be impermissible

The tool clarifies increased expectations for plan sponsors

Numerous revised and additional examples are provided in the body and appendix of the tool. Some examples revisit issues addressed in prior guidance, while others provide new insights on the application of MHPAEA’s NQTL rules. 

The examples were finalized based on the proposal with only minor modifications and clarifications. For more details about the proposal, see our June 22, 2020 article.

The tool also includes a resource intended to assist plan sponsors in comparing provider reimbursement rates for medical/surgical benefits and mental health/substance use disorder (MH/SUD) benefits.

In the final version of the tool, the departments published a nonexhaustive list that showcases the high degree and complexity of information that the DOL may ask a plan sponsor to provide in a federal audit to support its parity compliance. Information that may be requested includes:

  • Information about NQTLs that apply to MH/SUD and/or medical/surgical benefits offered under the plan or coverage
  • Records documenting NQTL processes and how the NQTLs are being applied to both medical/surgical and MH/SUD benefits to ensure the plan or insurer can demonstrate compliance with the law, including any materials that may have been prepared for compliance with any applicable reporting requirements under state law
  • Any documentation, including any guidelines, claims-processing policies and procedures or other standards that the plan or insurer has relied upon as the basis for determining its compliance with the requirement that any NQTL applicable to MH/SUD benefits be comparable to and applied no more stringently than the NQTL as applied to medical/surgical benefits
  • Samples of covered and denied MH/SUD and medical/surgical benefit claims
  • Documents related to MHPAEA compliance with respect to service providers (if a plan delegates management of MH/SUD benefits to another entity)
  • Any applicable MHPAEA testing completed by the plan or the insurer for financial requirements or quantitative treatment limits applied to MH/SUD benefits

Compliance plan best practices

The departments are encouraging plan sponsors to implement internal parity compliance plans that promote the prevention, detection and resolution of potential MHPAEA violations.

The tool suggests that an internal compliance plan should cover:

  • Training and education of claims reviewers, including anyone responsible on behalf of a plan or insurer, as well as education of participants and beneficiaries
  • Retention of all documents that support plan activities, as required under ERISA (including electronic information)
  • Internal monitoring and compliance reviews, including audits of samples of adverse benefit determinations, assessments of the application of medical necessity criteria, and reviews for completeness of information provided to claimants
  • Prompt response and corrective action if noncompliance is detected, which may include retroactive relief and notices to affected participants and beneficiaries

Next steps for plan sponsors

Expectations for group health plan sponsors regarding mental health parity continue to heighten. The tool makes it clear that the departments expect plan sponsors to perform MHPAEA assessments and carefully monitor and document parity compliance.

Many plans rely on third-party administrators and utilization-management companies to administer medical management processes that are NQTLs under MHPAEA. Plan sponsors will need to work closely with administrators to ensure parity compliance is achieved and documented.

Plan sponsors should develop formal, internal parity compliance plans that take into account all aspects of parity compliance.

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This page is for informational purposes only and does not constitute legal, tax or investment advice. You are encouraged to discuss the issues raised here with your legal, tax and other advisors before determining how the issues apply to your specific situations.

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