QUESTION: Our company’s self-insured group health plan provides both medical/surgical and mental health and substance use disorder benefits. We have heard that, to comply with the mental health parity rules, we have to prepare an NQTL comparative analysis. What is this, and how do we prepare it?
ANSWER: Health plans and insurers that provide both medical/surgical benefits and mental health or substance use disorder (MH/SUD) benefits—and that impose nonquantitative treatment limitations (NQTLs) on the MH/SUD benefits—are required to perform and document a comparative analysis of each NQTL’s design and application. As background, an NQTL is any limitation on the scope or duration of benefits that is not expressed numerically. Examples of NQTLs include limitations or exclusions based on medical necessity, facility type, prior authorization, or standards for admission to a provider network. In general, the processes, strategies, evidentiary standards, and other factors used to administer NQTLs for MH/SUD benefits must be comparable to and applied no more stringently than those used for medical/surgical benefits. Beginning February 10, 2021 (45 days after enactment of the Consolidated Appropriations Act, 2021) (see our Checkpoint article), comparative analyses and supporting documentation demonstrating compliance with these requirements must be provided to state or federal agencies and plan participants upon request.
The DOL, HHS, and IRS have provided details on the comparative analysis’ components and made clear that the analysis must include a “robust discussion” of nine specific elements along with supporting documentation (see our Checkpoint article). Conclusory or generalized statements without specific supporting evidence and detailed explanations are insufficient, as are productions of a large volume of documents without a clear explanation of relevance. The DOL’s mental health parity self-compliance tool, available on the DOL website (see our Checkpoint article), outlines a process for conducting comparative analyses. According to the DOL, plans that have carefully applied the guidance in that tool should be in a strong position to submit comparative analyses upon request.
The agencies have demonstrated an ongoing commitment to enforcing the mental health parity rules as they apply to NQTLs (see, e.g., our Checkpoint article). If they ultimately determine that a plan’s NQTL’s are not in compliance, then the plan must notify all enrollees within seven days of the determination. Assuming your self-insured plan applies NQTLs to MH/SUD benefits, you will want to work with your TPA (if applicable) to perform and document your analyses and be ready to provide them upon request. For more information, see EBIA’s Group Health Plan Mandates manual at Sections IX.E (“Mental Health Parity: Nonquantitative Treatment Limitations”) and IX.H.1 (“NQTL Comparative Analysis”).
Contributing Editors: EBIA Staff.
