On June 16, the US Departments of Labor, Health and Human Services, and Treasury (collectively, the “Departments”) released additional guidance under the Mental Health Parity and Addiction Equity Act (MHPAEA), as amended.

The guidance consists of a frequently asked question (FAQ) and a draft model form to help participants request information from health plans regarding nonquantitative treatment limitations that may affect their mental health or substance use disorder benefits or to obtain documentation to support an appeal after an adverse benefit determination involving such benefits.

Background

MHPAEA requires parity between mental health and substance use disorder benefits and medical and surgical benefits. This generally means that a plan’s coverage limits on mental health and substance use disorder benefits may not be more restrictive than its coverage limits on medical and surgical benefits. Such limits include financial requirements (e.g., deductibles, co-pays, coinsurance, and out-of-pocket limits) and treatment limits (e.g., limits on the number of days or number of visits covered and other limits on the scope or duration of treatment).

FAQ on Eating Disorders

The FAQ clarifies that eating disorders are mental health conditions. Accordingly, treatment of an eating disorder may not be subjected to limits that are any more restrictive than those applicable to medical and surgical benefits under a plan.

Model Participant Request Form

The draft model form is intended to help participants request both general and specific information from plans regarding mental health or substance use disorder benefits. It can be used after a claim denial by a plan or more generally, regardless of whether there has been a claim for benefits. Participants are not required to use the proposed form, but the availability of the form may increase the number of requests plans receive for this information.

The general request seeks information about limits on mental health and substance use disorder benefits generally or on a specific condition or disorder. The specific request asks for items such as

  • specific plan language regarding limits,
  • the factors used to develop limits and the evidentiary standards used to evaluate such factors,
  • the methods and analyses used to develop limits, and
  • any evidence used to establish that limits apply no more stringently to mental health and substance use disorder benefits than medical and surgical benefits.

To avoid potential penalties, plans must respond within 30 days of the date of a request. The Departments are soliciting comments on the draft model form by September 13, 2017.

Next Steps

Plans may consider reviewing the draft model request form to ensure that they are prepared to respond to any document requests. The guidance also provides a good excuse for plans to revisit their claims and appeals documents and procedures to ensure that they satisfy ERISA, which requires that some of this MHPAEA-required information be provided automatically in connection with a claim denial. Using an ERISA-compliant claim denial form may reduce the number of participant requests on the proposed forms. In addition, plans should examine any limits they impose on eating disorder treatment for compliance with the parity requirements.