Final regulations were released on the parity requirements for mental health and substance abuse last week.
The rules do not require mental health or substance abuse coverage, but if it is offered, it must follow these rules. Merely complying with new federal preventive care requirements, which may include some of these benefits, does not mean a plan must meet these rules if that is all it offers.
As before, the final rules require a lot of testing to make sure plans operate in a manner that puts mental health and substance abuse on level playing ground with other plan benefits. This includes testing on 6 key areas within health plans that offer mental health or substance abuse coverage. Those six categories include:
...inpatient in-network (with new sub-classes for multiple tiers of networks)
...inpatient out-of-network (with new sub-classes for multiple tiers of networks or office visits)
In simple terms, the plan design, coverage, and processes related to claims must be in "parity" or "equal terms" across these areas (or better). The new final rules took the requirements a step further to ensure that coverage and processes related to claims are on equal terms. The rules clarify that all benefits are covered, even intermediate care like residential or outpatient treatment.
As some examples, step therapy, provider reimbursement rates, facility type restrictions, network selection and restrictions (including georgraphic limits) should be on equal terms. This will include several processes, stategy, and evidentiary factors within health plans. Some locations previously excluded from coverage, may need to be included for coverage under these new rules. Finally, new notice requirements will also apply with regards to medical necessity for any particular treatment or coverage.
The final rules generally apply to group health plans for plan years beginning on or after July 1, 2014. Until the applicability date of the final rules, plans and issuers subject to MHPAEA must continue to comply with the interim final rules.
If you have questions on these rules, please contact Kinney & Larson.