Obama Releases Mental Health Parity Guidelines (posted 2/3)

The Departments of Health and Human Services, Education, and Labor released an interim final rule (IFR) providing guidance on how the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act must be implemented. To view the IFR click here.

This IFR goes into effect on Apr. 5 and applies to insurance plans with plan years starting on July 1 or later.  The IFR applies to group insurance plans of 50 or more people.  Although the Wellstone-Domenici law also applies to Medicaid managed care plans, these plans are NOT included in the IFR.  Additional guidance on how parity will apply to Medicaid managed care will be released by the Department of Health and Human Services in the future.  The Department of Health and Human Services is seeking comments on the IFR.  To post comments visit Regulations.gov keyword "mental health parity".

The National Council has released a parity fact sheet. To download the sheet click here.  The Departments of Health and Human Services, Education, and Labor has also released an IFR fact sheet.  To download the IFR fact sheet click here.  To read the HHS Press Release with more information click here.

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Behavioral Healthcare Magazine has provided a brief summary of the regulations:
To view these directly from Behavioral Healthcare click here.

The new regulations apply to six categories of benefits, meaning that if a plan offers mental health/addiction treatment benefits, they must be provided in all of the following classifications in which medical/surgical benefits are provided: 

• Inpatient- in network;
• Outpatient-in network;
• Inpatient-out of network;
• Outpatient-out of network;
• Emergency; and
• Prescriptions.

Within each of the six classifications, regulators stated that the financial requirements that apply to mental health/substance abuse benefits “cannot be more restrictive than the requirements or conditions that apply to substantially all medical/surgical benefits in the same classification unless recognized, generally accepted standards of care would permit such a difference.” 

Addressing fears from advocates about the potential for “separate” deductibles under the law, the regulations say that cumulative financial requirements, including deductibles and out-of-pocket limits, must be “integrated” between medical/surgical and mental health/addiction treatment. No separate deductibles will be allowed.

The new regulations also generally prohibit limitations on the quantity of treatment provided (i.e., the number of visits allowed in a given period), as well as limits based on non-qualitative factors such as:

• Medical management practices;
• Prescription drug formularies;
• Provider admission standards;
• Methods used to develop UCR charges;
• “Fail first” or “step therapy” protocols;
• Failure to complete a course of treatment; or
• Permanent exclusion of all benefits for a particular condition or disorder.

At this time, questions remain about how far current or yet-to-be released regulations will go in defining criteria for medical necessity and the scope of services applicable for mental health/substance abuse treatment under parity. While advocates are encouraged by what they’ve seen so far, lingering concerns about the ability of regulations to address the full range of “aggressive” medical management practices used by plans to limit treatment options and coverage still remain.

 

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