Final mental health parity rules issued Nov. 8 make several changes to the prior, interim version. The exemption for “clinically appropriate standards of care” was eliminated because regulators decided it was confusing and subject to abuse, and the rules’ application to “intermediate” coverage levels was clarified in response to uncertainty about how the interim rules’ benefit categories applied to coverage of specific treatment types and settings.
The final rules are scheduled to be published in the Nov. 13 Federal Register. The U.S. Departments of Labor, Health and Human Services and the Treasury kept the framework of the interim rules they issued in 2010 under the Mental Health Parity and Addiction Equity Act, which prohibits health plans that offer mental health or “substance use disorder” benefits from applying more restrictive financial or treatment limits than they apply to medical/surgical benefits.
Changes that DOL, HHS and Treasury made in the final rules include:
- ensuring that parity applies to intermediate levels of care received in residential treatment or intensive outpatient settings;
- clarifying the scope of the transparency required by health plans, including the disclosure rights of plan participants;
- clarifying that parity applies to all plan standards, including geographic limits, facility-type limits and network adequacy; and
- eliminating the “clinically appropriate” exemption for differences in nonquantitative treatment limitations.
“These rules will increase access to mental health and substance abuse treatment, prohibit discriminatory practices and increase health plan transparency,” said Labor Secretary Thomas Perez.
The final rules generally apply to group health plans and their health insurers for plan years beginning on or after July 1, 2014. Until then, plans subject to MHPAEA must continue to comply with the interim final rules.
The final rules eliminate the interim rules’ exception for “recognized clinically appropriate standards of care,” because the agencies decided it had been “confusing, unnecessary, and subject to potential abuse.” The underlying parity requirements for NQTLs (even without this exception) still should be flexible enough to allow plans and insurers to take appropriate standards into account when applying medical management techniques, for example, to medical/surgical benefits and mental health or substance use disorder benefits, according to the preamble.
NQTLs subject to the rules include “restrictions based on geographic location, facility type, provider specialty and other criteria that limit the scope or duration of benefits for services,” according to a frequently-asked-questions document posted by the agencies along with the final rules.
The final rules also apply parity requirements to benefits for intermediate levels of care for mental health conditions and substance use disorders. Plans must identify what is meant by an intermediate service for mental health and substance use disorder care and medical/surgical care, and must treat such intermediate-level services comparably within the structure of plan benefits.
Plans still may use multiple provider network tiers, provided they are consistent with the parity requirements. A plan that provides in-network benefits through multiple tiers of in-network providers may divide these benefits into sub-classifications that reflect those network tiers, if the tiering is based on reasonable factors and without regard to whether a provider is a mental health or substance use disorder provider or a medical/surgical provider.
Mental health parity requirements are detailed in the Employer’s Guide to HIPAA Compliance.