On June 16, 2017, the DOL issued a draft of a model disclosure request form that assists employees to seek information about an employer’s plan compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA). If an employer receives such a request, they will only have 30 days to respond. Please note that this is currently in draft form only. Public comment is being sought through September 13, 2017, regarding the disclosure process.
Background
The 21st Century Cures Act calls for better enforcement of compliance efforts with the MHPAEA. The MHPAEA originally went into effect on October 3, 2009. The final regulation went into effect January 13, 2014, and generally applies to plan years beginning on or after July 1, 2014.
The Requirements
The MHPAEA does not require group health plans to offer mental health or substance use disorder benefits. The regulation only applies to plans that are already choosing to offer these types of benefits.
Generally, the MHPAEA requires that health services and benefits for mental health and substance use disorders have similar requirements to substantially all other medical and surgical benefits offered by the plan. To determine if a plan is comparable, there are three important factors to consider: 1) financial requirements, 2) quantitative treatment limitations, and 3) non-quantitative treatment limitations.
- Financial Requirements generally include co-pays and deductibles.
- Quantitative treatment limitations include numerical limits, such as number of office visits.
- Non-quantitative treatment limitations include limits on the scope and duration of benefits and items such as standards for medical necessity, network tier design, reimbursement rates, exclusions based on failure to complete a course of treatment, geographic restrictions, and fail-first and step therapy protocols.
Mandatory MHPAEA Disclosures/Draft Model Form
The MHPAEA also requires certain disclosures be made by the health plan upon request by an employee. The new draft form will help facilitate these employee requests. Some of the mandatory disclosures include the following:
- Criteria for medical necessity determinations.
- Reasons for benefit denials.
- Any specific plan language regarding a mental health and substance use benefit limitation, along with all benefits to which the limitation applies.
- The factors used in the development of the limitation and the evidentiary standards used to evaluate the factors.
- The methods and analysis used in the development of the limitation.
- Evidence to establish that the limitation is applied no more stringently to mental health and substance use disorder benefits than to medical and surgical benefits.
Penalties
If the employer fails to respond to an employee request, a penalty of up to $110 per day may result.
Employer Best Practices
- Review the DOL Draft Form.
- Review plan policies and practices regarding Mental Health and Substance Use Disorders, if any, and ensure they comply with MHPAEA requirements.
Additional Resources
DOL Draft Model Disclosure Request
DOL MHPAEA Compliance Information
Centers for Medicare and Medicaid Services MHPAEA Information
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