On Sep. 9, DoL issued final rule mental health access, substance use.
DoL, CMS, and White House issued final rules to implement Mental health parity and addiction equity act (MHPAEA), as amended by Consolidated appropriations act, 2021.
Amended certain provisions of the existing MHPAEA (PL 110-343) regulations.
Add new regulations to set forth content requirements and timeframes for responding to requests for nonquantitative treatment limitation (NQTL) comparative analyses.
Added additional protections against the treatment limitations for mental health and substance use disorder (MH/SUD) benefits as compared to medical/surgical benefits.
Prohibit plans from using biased or non-objective data that might negatively impact mental health/substance use disorder care access when designing treatment limitation.
Health plans and health insurers must evaluate the impact of the nonquantitative treatment limitations (NQTLs) and must clarify requirements added to MHPAEA.
Plan or issuer may not impose any NQTLs re mental health/substance use benefits in any classification that is more restrictive, than NQTL in medical/surgical benefits.
Rule clarifies that MHPAEA protects plan participants from facing access restrictions.
Codify the requirement in MHPAEA, as amended by the 2021 Act, that health plans and issuers must conduct comparative analyses to measure the impact of NQTLs.
Requirements include evaluating standards related to network composition, out-of-network reimbursement rates, medical management and prior authorization NQTLs.
Prohibit plans/issuers from using discriminatory data that systematically disfavor or are specifically designed to disfavor access to mental heath/substance use benefits.
Implement sunset provision for self-funded non-Federal governmental plan elections to opt out of compliance with MHPAEA, per the Consolidated appropriations act, 2023.
Purpose and Meaning of Terms
Added purpose section to regulations, consistent with the statute, which emphasizes that plans must not design or apply financial requirements and treatment limitations.
That impose a greater burden on access to MH/SUD benefits under the plan than they impose on access to medical/surgical benefits in the same classification of benefits.
Amended definitions of the terms medical/surgical benefits, mental health benefits, and substance use disorder benefits by removing a reference to State guidelines.
Any condition, disorder, or procedure defined by the plan or coverage as being or as not being MH condition, SUD, medical condition, or surgical procedure must be defined consistent with generally recognized independent standards of current medical practice
Definition must follow the most current version of the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Plans and issuers may define it in accordance with applicable federal and State law if generally recognized independent standards do not address how to treat it.
Design and Application
General rule of the design and application requirements requires exam of processes, strategies, evidentiary standards used in designing and applying an NQTL to MH/SUD.
To ensure they are comparable to, and applied no more stringently than, those used in designing and applying limitation with respect to M/S benefits in same classification.
Prohibit the use of discriminatory factors and evidentiary standards to design an NQTL to be imposed on MH/SUD benefits; provided examples of biased and not based data.
Set relevant data evaluation requirements; provided list of examples of relevant data for NQTLs and additional data for NQTLs related to network composition standards.
Described how plan/issuer should comply with relevant data evaluation requirements when it newly imposes an NQTL for which relevant data is initially unavailable.
Or when no data exist that can reasonably assess any relevant impact on access.
MHPAEA Compliance
If data suggests that NQTL contributes to differences in mental health or substance use disorder benefit access compared to medical/surgical, may be MHPAEA violation.
Differences in access are not treated as material if they are attributable to medical or clinical standards or measures reasonably and designed to detect fraud and abuse.
If material differences in access exist, the plan or issuer must take reasonable action, as necessary, to address them to ensure compliance with MHPAEA in operation.
If an NQTL is not in compliance, plan/issuer may be directed to not impose the NQTL.
Plan or issuer must show compliance or take appropriate action to remedy violation.
NQTL Comparative Analysis
After initial request for a comparative analysis, plan/issuer must submit it to relevant Secretary within 10 business days (or an additional time specified by the Secretary).
If the comparative analysis is insufficient, the Secretary will specify the additional data necessary, which must be provided by the plan or issuer within 10 business days.
Also, if Secretary makes initial determination of noncompliance, plan or issuer has 45 calendar days to specify actions taken to comply and give more comparative analyses.
If Secretary makes a final determination of noncompliance, the plan or issuer must notify participants, beneficiaries, and plan enrollees not later than 7 business days.
Applicability Dates
Final rule provisions apply to group health plans and health insurance issuers that offer coverage starting on the first day of first plan year beginning on or after Jan. 1, 2025.
Certain obligations that take more time to implement apply on or after Jan. 1, 2026.
Additionally, the new rules apply to grandfathered and non-grandfathered individual health insurance coverage for policy years beginning on or after Jan. 1, 2026.
Sep. 23, 2024 Fed Reg Final Rule
On Sep. 23, 2024, DoL published final rule in federal register, effective Nov. 22, 2024.
