The final regulations implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 will become effective January 13.
The Act requires group health plans that offer mental health or substance use disorder benefits to ensure that those benefits are equivalent to the medical and surgical benefits offered by the plans.
The new final regulations apply to group health plans and health insurance issuers for plan years beginning on or after July 1, 2014. The final regulations define the law’s basic terms and outline the general parity requirement and classification of benefits.
The regulations state that the terms “mental health benefits” and “substance use disorder benefits” are to be defined by group health plans, but the definitions must be in accordance with applicable federal and state laws. They also must be “consistent with generally recognized independent standards of current medical practice.”
The general parity requirement refers to a plan’s financial requirements and treatment limitations. Financial requirements include copayments, deductibles, coinsurance, and out-of-pocket expenses and do not include aggregate lifetime or annual dollar limits. Treatment limitations include limits on treatment frequency, days of coverage, days in a waiting period, and other similar limits on the scope or duration of treatment.
Regarding classification of benefits, the interim regulations made clear that parity analysis must be conducted on a classification-by-classification basis. A plan can’t apply “any financial requirement or treatment limitation to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification.”
The final regulations divide benefits into the following six classifications: inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-of-network; emergency care; and prescription drugs. In addition, the final regulations allow plans and issuers to divide benefits furnished on an outpatient basis into two subclassifications: office visits (e.g., physician visits) and all other outpatient items and services (e.g., outpatient surgery, facility charges for day treatment centers, laboratory charges, and other medical items).
The final regulations also provide that if a plan provides in-network benefits through multiple tiers of in-network providers, the plan may divide benefits furnished on an in-network basis into subclassifications that reflect those network tiers. However, such tiering must be 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.