Expert Advice When You Need It Most
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity ActWritten by: Joni L. Landy Reputation Level 7
Posted over 2 years ago. 1 helpful vote, 0 comments
1
Prohibitions on Financial and Treatment LimitationsExisting law permits plans to limit the number of treatments or impose different cost sharing requirements for mental health benefits. Now under MHPAEA, in addition to the prohibitions on lower annual and lifetime limits, group health plans (or health insurance coverage offered in connection with such plans) are prohibited from imposing financial requirements and treatment limitations for mental health and substance abuse benefits that are more restrictive than those applied to medical and surgical benefits. In general, MHPAEA applies to group health plans maintained by an employer having more than 50 employees during the prior calendar year. Note that the law does not require plans to offer mental health and substance use benefits (although insured plans may be required to do so by state insurance law mandates). But, plans that do offer mental health and substance abuse benefits must comply with MHPAEA. 2
Financial RestrictionsFinancial requirements (deductibles, co-payments, coinsurance, and out-of-pocket expenses) for mental health or substance use disorder benefits may be no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan. Plans may not impose cost-sharing requirements that apply only to mental health or substance abuse disorder benefits. 3
Treatment RestrictionsTreatment limits (limits on frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment) applicable to mental health or substance use disorder benefits may be no more restrictive than the predominant treatment limitations applicable to substantially all medical and surgical benefits covered by the plan. Plans may not impose treatment limitations that apply only to mental health or substance abuse disorder benefits. 4
Out-of Network BenefitsPlans that offer out-of-network coverage for medical and surgical benefits will also be required to offer coverage for mental health and substance use disorder benefits on an out-of-network basis. 5
Increased Cost Exemption.A group health plan may qualify for an exemption on a year by year basis if compliance with MHPAEA results in an increase for a plan year of the total cost of coverage with respect to all benefits under the plan by two percent (2%) or more in the first year that MHPAEA applies to the plan (or by one percent (1%) or more in subsequent plan years). The exemption applies for the following year. MHPAEA requires plans to comply with the law for at least six months of the plan year involved before the exemption is available. The exemption requires determination and written certification by a qualified actuary of the cost increases and notification to governmental agencies, participants and beneficiaries of the plan's election to use the exemption. 6
Required Disclosuresa) Plan administrators (or health insurance issuers) must provide the criteria used for medical necessity determinations with respect to mental health or substance use disorder benefits to any current or potential participant, beneficiary, or contracting provider upon request in accordance with regulations to be issued. (b) The reasons for denial of payment for mental health and substance abuse benefits must be provided by the plan administrator (or health insurance issuer) to participants or beneficiaries upon request in accordance with regulations to be issued. 7
Effective DatesFor non-collectively bargained plans, the effective date is the plan year beginning after October 3, 2009. For calendar year plans this means January 1, 2010. For non-calendar year plans beginning November 1 or December 1, the effective date is in 2009. For example, November 1, 2009 is the effective date for a plan with a plan year running from November 1- October 31. For group health plans maintained pursuant to a collective bargaining agreement, MHPAEA will be effective on the later of: (a) the date on which the last of the collective bargaining agreements relating to the plan terminates (without regard to any extension agreed to after October 3, 2008), or (b) January 1, 2010. Additional ResourcesSee Compliance Dates Approaching on Three More Laws Affecting Group Health Plans posted on the Medlaw Blog for further information on this topic. Related Questions1 Attorney answers: 
Asked by a user in Lafayette, CA - 6 months ago. 3 Attorney answers: 
Asked by a user in Jacksonville, FL - 5 months ago. 2 Attorney answers: 
Asked by a user in Saint Petersburg, FL - 5 months ago. Find Franchising LawyersRelated Searches |