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DOL FAQs Address MHPAEA Compliance
Practical Law Legal Update 4-519-6028 (Approx. 5 pages)
DOL FAQs Address MHPAEA Compliance
by PLC Employee Benefits & Executive Compensation
| Published on 23 May 2012 • USA (National/Federal) |
On May 18, 2012, the Department of Labor (DOL) issued frequently asked questions (FAQs) on the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The FAQs address numerous MHPAEA issues, including the use of financial requirements and treatment limitations on mental health and substance use disorder benefits.
On May 18, 2012, the DOL's Employee Benefits Security Administration (EBSA) issued FAQ guidance addressing the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA generally applies to group health plans and health insurers that provide coverage for either medical/surgical benefits or mental health or substance use disorder benefits. These FAQs provide information for employees about MHPAEA's protections regarding parity between group health plan coverage of medical/surgical benefits and mental health and substance use disorder benefits. Among other things, the FAQs explain that:
- While plans may no longer have separate deductibles for medical/surgical benefits and mental health or substance use disorder benefits, they are generally permitted to combine these deductibles. The FAQs include the example of a plan that formerly had a:
- $500 deductible on medical/surgical benefits; and
- $500 deductible on mental health or substance use disorder benefits.
The plan in this example could now use a combined $750 deductible for all benefits, though a separate deductible for mental health or substance use disorder benefits would not be permitted. - An individual who is denied mental health benefits is entitled to receive certain information from the plan under:
- MHPAEA, which requires that a group health plan's criteria for medical necessity determinations regarding mental health or substance use disorder benefits be made available by the plan administrator or insurer to participants and beneficiaries on request;
- ERISA's requirement to furnish certain documents to participants or beneficiaries within 30 days of written request, which, according to the DOL, includes documents with information on the medical necessity criteria for both medical/surgical benefits and mental health or substance use disorder benefits (see Practice Note, ERISA Litigation: Penalties for Failing to Provide Documents);
- the DOL claims procedure regulations (for more information, see Practice Note, Internal Claims and Appeals Under the ACA); and
- the Affordable Care Act's (ACA's) external review requirements, applicable to non-grandfathered health plans (for more information, see Practice Notes, External Review Under the ACA and Grandfathered Health Plans Under the ACA).
- To determine if a quantitative financial requirement (for example, a copayment) or quantitative treatment limitation (for example, a visit limit) is permissible, the parity analysis must be applied for that type of financial requirement or treatment limitation within a coverage unit (for example, self-only or family) for each of six classifications of benefits separately. The FAQs define a coverage unit and list the six classifications of benefits as:
- inpatient in-network;
- inpatient out-of-network;
- outpatient in-network;
- outpatient out-of-network;
- emergency care; and
- prescription drugs.
- Employees can obtain more information about MHPAEA's requirements:
- On the DOL's MHPAEA webpage.
- By contacting an EBSA regional office.
- By calling (866) 444-3272 (toll free).
For more information, see Mental Health Parity (MHPAEA) Toolkit.
Practical Impact
These FAQs are the latest in a series of MHPAEA-related developments that include:
- FAQs issued in November 2011 and May 2012 (see, respectively, Legal Updates, DOL Issues FAQs on the ACA and the Mental Health Parity Requirements and DOL Issues FAQs on Mental Health Parity and Addiction Equity Act).
- EBSA's webpage on MHPAEA compliance.
Collectively, this guidance may suggest that MHPAEA is becoming a greater enforcement priority for the DOL, though the agency notes in one of its new FAQs that its intent is to work with plans, insurers and service providers to assist them in complying with MHPAEA. Also, while the DOL refers to these new FAQs as providing basic information about MHPAEA's requirements, at least some of the FAQs reflect the complexity of performing parity analysis for certain plan designs.