Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act (MHPAEA); Final 2020 MHPAEA Self-Compliance Tool Preface
The DOL has finalized the biennial update of its self-compliance tool designed to help employers comply with the Mental Health Parity and Addiction Equity Act (MHPAEA). The 2020 update integrates recent MHPAEA guidance and includes revised compliance examples, best practices for establishing an internal compliance plan, and “warning signs” that may indicate potential violations. The update is similar to the proposed version released in June 2020 (see our Checkpoint article) but includes “minor modifications and clarifications” based on public comments. Here are highlights of those modifications:
Provider Reimbursement Rates. The final update includes an additional warning sign that may be indicative of MHPAEA noncompliance—the consideration of different sets of factors to establish provider reimbursement rates. As an example, a plan that considers market dynamics, supply and demand, and geographic location to set reimbursement rates for medical/surgical benefits might violate the parity rules if it considers only quality measures and treatment outcomes in setting reimbursement rates for mental health/substance use disorder (MH/SUD) benefits. A revised note clarifies that the MHPAEA’s requirements for nonquantitative treatment limitations (NQTLs) apply to methods for establishing both in-network and out-of-network provider reimbursement rates. And Appendix II (which includes a tool for comparing a plan’s reimbursement schedule to Medicare rates) now explains that comparing a plan’s average reimbursement rates for both medical/surgical and MH/SUD providers with an external benchmark of reimbursement rates, such as Medicare, may help identify whether the underlying methodology used to determine the plan’s reimbursement rates warrants additional review for MHPAEA compliance.
Internal Compliance Plans. The final update continues to emphasize that internal compliance plans, while not required by the MHPAEA, promote the prevention, detection, and resolution of potential parity violations and can help plans comply with the law. Characteristics of successful internal compliance plans are listed, including training and education, records retention, internal monitoring, and compliance review. The final update adds that plans that delegate benefits management to other entities should ensure that service providers for both medical/surgical and MH/SUD benefits provide documentation necessary for the plan to ensure compliance. It also reminds plans of the importance of maintaining any documentation that may be prepared for compliance with applicable state law reporting requirements.
NQTLs. The compliance tool devotes significant attention to NQTLs—treatment limitations that are not expressed numerically—and provides as one example standards for provider admission to participate in a network. The final update notes that a plan network that includes far fewer MH/SUD providers than medical/surgical providers is a red flag that the plan may be imposing an impermissible NQTL. The final update also includes a new note addressing residential treatment limitations. If a plan classifies covered intermediate levels of care, such as skilled nursing care and residential treatment, as inpatient benefits, and covers room and board for all inpatient medical surgical care but imposes a restriction on room and board for MH/SUD residential care, the plan imposes an impermissible restriction only on MH/SUD benefits. The plan could come into compliance by covering room and board for intermediate levels of care for MH/SUD benefits comparably with medical/surgical inpatient treatment.
EBIA Comment: The self-compliance tool remains a valuable resource for MHPAEA compliance, and group health plan sponsors and advisors should take full advantage. For more information, see EBIA’s Group Health Plan Mandates manual at Section IX (“Mental Health Parity”). See also EBIA’s Self-Insured Health Plans manual at Sections XIII.C (“Federally Mandated Benefits”) and XIII.E (“Coverage Limitations and Exclusions”).
Contributing Editors: EBIA Staff.