The Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans to ensure that their mental health benefits are provided equivalent to their medical/surgical benefits. This includes (but is not limited to) equivalence in claim payouts, waiting time for claim approval, and procedural hurdles before a claim can be submitted. The mental health parity rules in practice have not been consistently enforced and some health insurance plans have used certain legal loopholes to avoid treating mental health claims the same way as medical claims.

In an attempt to close some of the MHPAEA loopholes, the Federal Government is initiating official rulemaking. This proposed rule will put teeth back into the mental health parity law and more clearly spell out MHPAEA requirements to promote more consistent compliance and enforcement. The primary change (for plans and issuers) will be a requirement to collect outcomes data for group health plans (that have or wish to implement a Nonquantitative Treatment Limitation, or NQTL) to ensure that mental health benefits are administered no more stringently than medical/surgical benefits. This would include tracking utilization rates and response time for claim submissions.

Other important proposed changes are outlined below:

- A strong statement of purpose for the MHPAEA. By including this statement, the Federal Government hopes to inform plans of the purpose of the MHPAEA, aiding in compliance both on the plan end (they can more easily determine what policies are permitted under the MHPAEA) and on the government end (more exacting definitions make enforcement easier). The statement of purpose places a strong emphasis on preventing policies that create a disparity in access to care.

- Alterations to existing definitions of certain key terms. Specifically “medical or surgical benefits”, mental health benefits”, and “substance use disorder benefits” are to be defined with reference to the plan. However, where the plan does not address a certain benefit, the benefits must be construed in a way that is consistent with generally recognized independent standards of current medical practice. These definitions will lose their current references to state guidelines so as to prevent state guidelines from improperly limiting access to benefits. This change will give less leeway for plans to determine what qualifies as a mental health benefit.

- Under the proposed rules, eating disorders, such as anorexia nervosa, bulimia nervosa, and binge-eating disorder, will be considered mental health conditions under generally recognized independent standards of current medical practice.

- Under the proposed rules, ASD (autism) is also considered a mental health condition under generally recognized independent standards of current medical practice.

- A renewed focus on how Nonquantitative Treatment Limitations (NQTL) are applied to benefits and more stringent standards with regard to if an NQTL is more restrictive for mental health benefits than medical/surgical benefits.

As previously stated, this is a proposed rule and must still pass through the notice and comment period before becoming an actual amendment to the MHPAEA. FNA Insurance Services, Inc. will follow the trajectory of this proposed rule and inform you of significant updates as they happen.

You can read the entire proposed rule HERE.