The effect of the Mental Health Parity and Addiction Equity Act (MHPAEA) on prior authorization practices and other “nonquantitative treatment limitations” was clarified Nov. 17 in guidance from the U.S. Department of Labor (DOL).
The MHPAEA interim final rules issued in February 2010 imposed a detailed numerical formula for determining whether quantitative limits such as copayments and deductibles meet the act’s standards for parity. For nonquantitative limits, the rules were naturally more nebulous; factors used to apply these limits to mental health and “substance use disorder” benefits must be comparable to, and no more stringent than, those used for medical/surgical benefits, unless justified by “clinically appropriate standards of care.”
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A group health plan may not require prior authorization for all mental health benefits while not requiring it for any medical/surgical benefits, because prior authorization is a nonquantitative treatment limitation, according to one of the frequently asked questions (FAQs) DOL prepared jointly with the U.S. Departments of Health and Human Services (HHS) and the Treasury.
And even if, for example, prior authorization is required for all inpatient benefits of either kind, a plan may not have a practice of routinely approving inpatient medical benefits for seven days, but mental health benefits for only one day. “The plan is applying a stricter nonquantitative treatment limitation in practice to mental health and substance use disorder benefits than is applied to medical/surgical benefits,” DOL explained.
Requiring prior authorization for all outpatient mental health benefits but only a few types of outpatient medical/surgical benefits also would be prohibited. “It is unlikely that the processes, strategies, evidentiary standards, and other factors” that the plan used to decide that only the few medical benefits warranted pre-authorization, would at the same time require it for all outpatient mental health and substance use disorder benefits, DOL indicated.
However, a plan may apply concurrent review to inpatient care where length of stay varies widely, even if in practice this affects mental health conditions more often, DOL noted, as long as “the evidentiary standard used by the plan is applied no more stringently for mental health and substance use disorder benefits than for medical/surgical benefits.” (The full text of the FAQs is available.)
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