Changes Coming for MHPAEA Compliance

The federal agencies responsible for enforcing the Mental Health Parity and Addiction Equity Act (MHPAEA) recently issued additional guidance directed at compliance with the MHPAEA as amended by the ACA and the Cures Act.  This guidance clarifies that eating disorders are mental health conditions subject to the parity requirements and offers a model form that health plan participants can use to request more detailed information about their plans’ compliance with those requirements.

The Cures Act and the agencies’ most recent FAQ clarify that eating disorders are mental health disorders, and coverage for the treatment of eating disorders is subject to the MHPAEA, meaning that any limitations placed on the treatment of eating disorders must be no more restrictive than the limitations imposed on medical/surgical benefits.

In general, the MHPAEA requires that benefits for mental health and substance use disorders (MH/SUD) are equal to benefits provided for medical/surgical treatments.  These parity requirements apply to financial limitations, quantitative treatment limitations, and non-quantitative treatment limitations (NQTLs) in eight plan classifications.  NQTLs include medical standards that limit or exclude benefits based on medical necessity or medical appropriateness or whether a treatment is experimental or investigational.  Many plan designs are comparable with respect to financial and quantitative treatment limitations, but not with respect to NQTLs.

The agencies released a draft model form (Draft Form) that participants, or a participant’s authorized representative, can use to request general information related to their MH/SUD benefits under their group health plan and any limitations impacting those benefits.  The Draft Form is specifically intended to request information to demonstrate whether the application of NQTLs to MH/SUD benefits is comparable to application to medical/surgical benefits.  The Draft Form can also be used to obtain documentation related to an adverse benefit determination that could assist participants with appeals.  An employer has 30 days to respond to such requests.

Comments on this guidance are due September 13, 2017.  If you have questions about the parity requirements, call ASR Health Benefits at (616) 957-1751 or (800) 968-2449.