People Processes: Deep Dive into Mental Health Parity and Autism Diagnosis

What this episode covers

EBSA issues array of guidance on mental health parity EBSA has released an array of guidance on the Mental Health Parity and Addiction Equity Act (MHPAEA), including proposed Frequently Asked Questions, an enforcement fact sheet, a self-compliance tool, and a revised draft disclosure template. In addition, the DOL has released a report to Congress that outlines its current implementation and enforcement actions in furtherance of the MHPAEA. Background. In general, MHPAEA requires that the financial requirements (such as coinsurance and copays) and treatment limitations (such as visit limits) imposed on mental health or substance use disorder (MH/SUD) benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits in a classification. With regard to any nonquantitative treatment limitation (NQTL), the MHPAEA final regulations provide that a group health plan or health insurance issuer may not impose an NQTL with respect to MH/SUD benefits in any classification unless, under the terms of the plan (or health insurance coverage) as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits in the classification are comparable to, and are applied no more stringently than the processes, strategies, evidentiary standards, or other factors used in applying the limitation to medical/surgical benefits in the same classification. MHPAEA also imposes certain disclosure requirements on group health plans and health insurance issuers. FAQs on NQTL. The proposed FAQs, which were prepared jointly by the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (Departments), were developed consistent with Section 13001(b) of the 21st Century Cures Act. Section 13001(b) requires that the Departments issue clarifying information and illustrative examples of methods that a plan or issuer offering group or individual health insurance coverage can use to disclose information in compliance with MHPAEA. Section 13001(b) also directs the Departments to issue clarifying information and illustrative examples of methods, processes, strategies, evidentiary standards, and other factors that plans and issuers may use regarding the development and application of NQTLs. Experimental treatment. The FAQs first address whether it is permissible for a plan to deny claims for Applied Behavioral Analysis (ABA) therapy to treat children with Autism Spectrum Disorder under the rationale that the treatment is experimental or investigative. With respect to medical/surgical conditions, the plan approved treatment when supported by one or more professionally recognized treatment guidelines and two or more controlled randomized trials. A medical management standard limiting or excluding benefits based on whether a treatment is experimental or investigative is an NQTL under MHPAEA. Although the plan as written purports to exclude experimental or investigative treatment for both MH/SUD and medical/surgical benefits using the same standards, in practice, it imposes this exclusion more stringently on MH/SUD benefits, as the plan denies all claims for ABA therapy, despite the fact that professionally recognized treatment guidelines and the requisite number of randomized controlled trials support the use of ABA therapy to treat children with Autism Spectrum Disorder. Accordingly, because the plan applies the NQTL more stringently to mental health benefits than to medical/surgical benefits, the plan’s exclusion of ABA therapy as experimental does not comply with MHPAEA. Likewise, a plan does not comply with the MHPAEA where it defines experimental or investigative treatments as those with a rating below “B” in the Hayes Medical Technology Directory, but the plan reviews and covers certain treatments for medical/surgical conditions that...