Recently, the federal Departments of Labor, Treasury, and Health and Human Services (collectively, the “Agencies”) jointly issued a set of frequently asked questions and responses (the “FAQs”) that (i) provide additional examples of applying the Mental Health Parity and Addiction Equity Act, as amended (“MHPAEA”), to various fact patterns and (ii) finalize previous guidance issued by the Agencies in 2018 (see our prior blog post on that guidance here).
The MHPAEA generally prohibits group health plans and issuers from imposing financial requirements (such as coinsurance or copays) or treatment limitations (such as visit limits or other “non-quantitative” limitations) on “mental health benefits” and “substance use disorder benefits” (collectively, “MH/SUD Benefits”) that are more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical and surgical benefits (collectively, “Med/Surg Benefits”). The fact situations addressed in the FAQs include the following:
• A group health plan’s imposition of a limitation or exclusion on the payment of MH/SUD Benefits and Med/Surg Benefits when the treatment in question is experimental or investigational;
• A group health plan’s establishment and administration of dosage limitations for prescription medications with respect to MH/SUD Benefits and Med/Surg Benefits; and
• The establishment and administration of a methodology for developing and applying provider reimbursement rates and admitting providers to participate in a network for a group health plan.
Along with the FAQs, the Agencies issued a finalized version of the “model disclosure request form” that had been issued in proposed form in 2018. The model disclosure request form may be used by group health plan participants or their authorized representatives to request certain MH/SUD Benefits-related documentation and information from the plan administrator that participants are entitled to receive under ERISA. The Agencies confirmed that, although it may be helpful in streamlining requests for documentation or information, use of the model disclosure request form is not required by group health plans.
The FAQs and model disclosure request form are available here.