DOL Fact Sheet: FY 2019 MHPAEA Enforcement; Appendix: MHPAEA Violation Guidance Compendium (March 2020)
The DOL has issued a fact sheet regarding 2019 mental health parity enforcement activity conducted by the DOL and (with respect to non-federal governmental group health plans) the Centers for Medicare & Medicaid Services (CMS). The fact sheet and its accompanying appendix detail the agencies’ enforcement strategy, explain the investigation process, and provide examples of 2019 enforcement actions. Here are highlights:
Enforcement Strategy. The DOL works with insurers and other service providers (such as TPAs) to obtain voluntary global corrections when a violation relates to plan provisions or operations affecting multiple health plans. Thus, compliance is achieved for all affected plans, not just the plan under investigation.
Investigation Process. The DOL receives inquiries from plan participants who believe their mental health or substance use disorder benefits were improperly denied. If DOL staff are unable to obtain voluntary compliance, a formal investigation may be opened. During the investigation, plans are reviewed for compliance with all aspects of the parity rules, including the requirements for quantitative treatment limitations (QTLs) and nonquantitative treatment limitations (NQTLs). If violations are found, noncompliant plan provisions must be removed, and the plan must pay any improperly denied benefits.
Enforcement Actions. In 2019, the DOL and CMS closed 185 mental health parity investigations resulting in 12 citations for violations in six categories—annual dollar limits; aggregate lifetime dollar limits; provision of benefits in all permitted classifications; cost-sharing requirements; treatment limitations (including NQTLs); and cumulative financial requirements and QTLs. In one case, a service provider working with multiple plans imposed a medical necessity review requirement on outpatient mental health and substance use disorder benefits after 30 visits. Although the service provider indicated there was a similar requirement for medical and surgical benefits, the investigation showed that the plans permitted 52 medical and surgical visits before requiring medical necessity review. The plans were required to increase to 52 the number of mental health and substance use disorder visits allowed without a medical necessity review, and the service provider was required to re-adjudicate 198 claims in nine different plans, resulting in payouts totaling $19,744 to 29 participants. The investigation also revealed that the same service provider had disallowed claims for drug screening tests only for individuals who had been diagnosed with a substance use disorder. The service provider was required to amend its claims procedures and re-adjudicate claims for 12 plans, resulting in an additional payout of $146,278 to 32 plan participants.
EBIA Comment: The agencies continue their steadfast commitment to mental health parity enforcement. Plan sponsors, advisors, and insurers should take notice and take steps to ensure compliance. For more information, see EBIA’s Group Health Plan Mandates manual at Sections IX.A (“What Is Mental Health Parity and Who Must Comply?”) and IX.J (“Mental Health Parity: Enforcement”). See also EBIA’s Self-Insured Health Plans manual at Section XIII.E (“Coverage Limitations and Exclusions”).
Contributing Editors: EBIA Staff.