More government audits and ramped up enforcement of the Mental Health Parity and Addiction Equity Act.
That’s what we can expect from the U.S. Department of Labor in the months and years ahead, thanks to provisions in the Consolidated Appropriations Act that have unleashed huge changes in group healthcare benefits.
Among the changes, the CAA amended the MHPAEA to now require employers to analyze the nonquantitative treatment limitations used for medical and surgical benefits in their plans and compare them to mental health and substance use disorder (MH/SUD) benefits.
Quantitative treatment limitations have a numerical value, such as the number of times a patient can see a doctor or the number of days they are authorized to spend in a treatment facility.
Nonquantitative limitations, on the other hand, have no numerical value, and can include items such as a prescription drug formulary, which is a list of the medications a health plan will cover. If a drug isn't on the list, a patient generally can't obtain benefits for it.
The parity requirements have been law for some time. What’s new thanks to the CAA is a requirement that health plans perform a six-step NQTL analysis to prove that there is, in fact, parity between their medical and mental health benefits.
Why is parity necessary? Because lawmakers and regulators want to ensure people who need mental health services get appropriate care and that any associated stigmas are removed.
Failure to comply could well mean civil monetary penalties. Perhaps more seriously, we could see health plan participants and beneficiaries turn to the courts with allegations of parity violations.
And now, with a CAA-imposed parity analysis obtained by their attorneys during discovery, they’ll have the hard evidence in hand that sways juries.
How serious are regulators about all this? Here’s a telling passage from a recent report to Congress from the Employee Benefits Security Administration, which is part of the DOL, the Department of Health and Human Services, and the IRS:
“(We) are committed to using all … available authority to ensure that individuals realize the full promise of MHPAEA, and to ensure that Americans with MH/SUD coverage can access MH/SUD care that is not limited in any way that medical/surgical care is not.
“The Departments have determined that this goal can only be achieved through proactive and rigorous enforcement of MHPAEA. To that end, EBSA and HHS have dedicated significant resources to strengthening their enforcement efforts. This includes developing and conducting extensive training for existing agency staff, recruiting and retaining additional staff, and employing experts when necessary.”
At the time the agencies’ report was written, none of the companies that had been audited were able to furnish regulators with an NQTL analysis that passed muster.
Finally, if you hear from the government, it’s highly unlikely you’ll have adequate time to prepare a proper analysis with all of the information required. In other words, don’t wait; get your group health plan administrators moving.
The Mahoney Group is one of the largest independent commercial insurance and employee benefits brokerages in the U.S. For more information, contact us online or call 877-440-3304.
This article is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel or an insurance professional for appropriate advice.