QUESTION: Our company has been notified that the DOL is conducting a mental health parity investigation of our group health plan. What should we expect?
ANSWER: The DOL has authority to enforce mental health parity compliance by employer-sponsored group health plans that are subject to ERISA. It has provided the following information regarding its Mental Health Parity and Addiction Equity Act (MHPAEA) enforcement program:
-
Investigations of potential MHPAEA violations can begin with referrals from agency benefit advisors, leads from other agencies, feedback from consumer groups, or utilization of “advanced targeting methods” that “incorporate various sources.”
-
The first step is to obtain documents containing or describing plan provisions regarding medical and surgical benefits and benefits for mental health and substance use disorder. These could include the plan document, summary plan description, certificate of coverage, contracts with third-party administrators or other service providers, and internal guidelines used by the plan.
-
DOL may also request information regarding covered and denied claims to determine whether a plan’s operation is consistent with the provisions of its plan document. A typical MHPAEA case can involve analyzing thousands of individual claims over a period of several years.
-
Any plan provisions that may violate the MHPAEA will be addressed with representatives of the plan sponsor, and with the health insurer or third-party administrator. The investigator will examine additional documents identified through these conversations.
-
After completing the initial analysis of a potential MHPAEA issue, the investigator may coordinate with subject matter experts within the DOL and with HHS and Treasury. If the plan is fully insured, the investigator may also coordinate with a state insurance department.
-
If it is determined that the plan has violated the MHPAEA, the investigator will attempt to achieve voluntary correction by sending a letter to the plan sponsor with preliminary investigation findings.
-
If the plan sponsor or insurer is willing to remedy the MHPAEA violation, the investigator will work to identify the appropriate way to redress the violation and will monitor its implementation. This may require reprocessing of previously denied claims with potential refunds to participants for cost-sharing amounts. Plan documents and plan practices may also need to be updated. Once this is done, the investigator will send a closing letter to the plan sponsor advising that the investigation is closed.
-
If the plan sponsor or insurer is not willing to voluntarily correct the issue, the investigator and other representatives from the DOL will meet with plan officials or the insurer. If the issues are still not resolved, the case may be referred to the DOL Solicitor’s Office for potential litigation, at which point the investigator’s status changes from conducting the investigation to providing litigation support.
For more information, see EBIA’s Group Health Plans 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.C.2 (“MHPA and MHPAEA: Mental Health Parity”).
Contributing Editors: EBIA Staff.
