In June 2017, the U.S. Departments of Labor, Treasury and Health and Human Services provided guidance under the Mental Health and Parity and Addiction Equity Act (MHPAEA). Released in the form of a Frequently Asked Question, the guidance also included a model form as assistance to participants for requesting a plan’s mental health or substance use disorder benefits, or to obtain documentation in support of an appeal.
The MHPAEA requires that financial requirements and treatment limitations for mental health and substance use disorder be in parity with the financial requirements and treatment limitations applicable to medical and surgical benefits. In plain language this means a plan’s coverage limits on mental health and substance use disorder benefits may not be more restrictive than medical and surgical benefits. Financial requirements include deductibles, copayments, coinsurance and out-of-pocket maximums. Treatment limitations reference limits on the number of days or number of visits covered and/or limits on the scope or duration of treatment.
Group health plans are required to disclose certain information to plan participants regarding coverage of mental health/substance use disorder benefits under the MHPAEA. Under the disclosure requirements, plan and insurers must:
• Disclose the criteria for medical necessity determinations related to mental health/substance use disorder benefits to current participants, beneficiaries, or contracting providers on request; and
• Provide the reason for denials (often referred to as an “adverse benefit determination”) of reimbursement or payment of mental health/substance use disorder benefits.
Plans that are subject to ERISA (private employer plans) include further disclosure requirements to plan participants, upon request, about the processes, strategies, evidentiary standards, and other factors used
to make a determination under its claim denial procedures.
Model Participant Request Form
The Departments issued a model form in June that may be used by health plan participants and their representatives to request plan documents concerning a plan’s or insurer’s MHPAEA related compliance. Along with other general information, the request form reminds employers subject to ERISA that the plan must provide plan documents addressing benefits upon request from a plan participant within 30 days of receiving a written request. The form further allows for a participant to seek information on a specific condition or disorder by requesting:
• Specific plan language regarding limits;
• Identify the factors used in the development of the limitations and evidentiary standards used to evaluate the factors;
• The methods and analyses used to develop limits; and
• Provide evidence showing that the limit is applied no more stringently to mental health/substance use disorder benefits than medical/surgical benefits.
The draft form is not required to be used by a participant when requesting information and a plan/insurer must respond to information requests even if the form is not used. However, the Departments indicated that a model form is helpful to participants when asking for information, and is more uniform and streamlined.
The same FAQ issued by the Departments in June also provided that an eating disorder is a mental health condition. As such, the benefits for the treatment of an eating disorder must be in parity with a plan’s medical and surgical benefits.
The provision of benefits for mental health/substance use disorder treatments continues to be on the radar of the regulatory Departments. Employer plans that are subject to ERISA should know that the issue of parity under the MHPAEA is a major issue under a DOL investigation. Plans may want to review the draft model request form in order to be prepared for any requests. This would also be a good opportunity for an employer to review the plan document’s claims and appeals process and procedures, to ensure compliance with ERISA. The model form can be used until finalized.