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Question of the Quarter: June 2016

What are some red flags that plans should be on the lookout for to ensure they remain in compliance with Mental Health Parity when imposing non-quantitative treatment limitations?

 

On June 1, 2016, the Department of Labor (DOL) issued a checklist of examples that can serve as red flags for plans that may be imposing non-quantitative treatment limits that are out of compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA). 

 

As a reminder, MHPAEA applies to employers who had an average of at least 51 employees in the preceding calendar year and maintain a plan that was effective on or after January 1, 2010. MHPAEA does not require plans to cover mental health and substance abuse services, but if a plan chooses to cover those services they must be in parity with medical and surgical services also offered.

 

The DOL has indicated that the list, included in the chart below, is not all inclusive, but is meant to show where plans may need to review the factors used to determine non-quantitative treatment limits when similar restrictions are not placed on medical/surgical benefits.

 

The chart below summarizes the DOL’s red flag checklist:

 

CategoryExamples
Preauthorization notification requirements
  • Preauthorization for all mental health and substance use disorder treatments
  • Preauthorization for Treatment Facility Admission 
  • Medical Necessity Review for MH/SUD services
  • Preauthorization quarterly reviews for medications to treat MH/SUD
  • Pre-notification for inpatient services, outpatient treatments and treatments beyond 45-50 minutes
Fail-first protocols
  • Requires documentation of no progress with outpatient treatment
  • Requires two or more forms of outpatient treatment prior to granting inpatient care
Probability of improvement
  • Requires likelihood that inpatient treatment will improve status or that results will be measureable within 90 days
Require written treatment plan
  • Requires a written treatment plan as well as weekly progress updates in addition to bi-annual updates
Other areas of concern
  • Excluding coverage if treatment ends against medical advice
  • Residential treatment limits for chemical dependencies
  • Geographical limits not imposed on medical/surgical benefits
  • Licensing limits not imposed on medical/surgical benefits

 

If you have any questions, please contact your Client Solutions team.

 

Compliance Quarterly is being provided as an informational tool. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this publication and any attachments, Meritain Health is not exercising discretionary authority over the plan and is not assuming a plan fiduciary role, nor is Meritain Health providing legal advice.