The Wagner Law Group
Wagner Law Group, A Professional Corporation, is a nationally
recognized ERISA & employee benefits, estate planning,
employment, labor & human resources practice.
in 1996, The Wagner Law Group has 22 attorneys engaged
exclusively in employee benefits, estate planning and
employment law. Six of our attorneys are AV rated by
Martindale-Hubbell as having very high to preeminent legal abilities
and ethical standards. The firm is among the largest ERISA boutiques
in the country. Our practice is national in scope, with clients in
more than 40 states and several foreign countries.
Wagner Law Group
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June 23, 2016
Health and Welfare Law
New Guidance from DOL on
Mental Health Parity and Addiction Equity Act
has released guidance on certain provisions commonly found in group
health plans that may constitute impermissible limits on mental
health/substance use disorder ("MH/SUD") benefits and
thereby violate the Mental Health Parity and Addiction Equity Act
Background. The MHPAEA applies to group health
plans sponsored by an employer or employee organization, that cover
both medical/surgical and MH/SUD benefits. Specifically, MHPAEA
requires group health plan sponsors to ensure that the financial
requirements and treatment limitations on MH/SUD benefits are no more
restrictive than those on medical or surgical
("med/surgical") benefits. In other words, MHPAEA requires
group health plan sponsors to provide MH/SUD benefits in parity with
issued requirements for determining parity regarding financial
requirements (e.g., copays) and for treatment limitations,
that limit the scope or duration of benefits. Treatment
limitations may be quantitative treatment limitations (i.e.,
numerical limits) or non-quantitative treatment limitations
("NQTLs"), such as preauthorization requirements.
Guidance. The DOL
guidance focuses on NQTLs and how to identify provisions that will
require plan sponsors to make inquiries beyond the plan's or
insurance policy's terms to determine whether the MHPAEA parity
requirements have been satisfied.
particular, the guidance includes examples of plan provisions that
present red flags that a plan may be imposing impermissible NQTL on
MH/SUD benefits. The DOL notes that plan terms with such
language do not automatically violate MHPAEA, but that the plan
sponsor will need to present evidence to substantiate compliance.
examples of group plan provisions that require further review by plan
sponsors (to confirm compliance with MHPAEA's NQTL parity
requirements) include the following:
preauthorization requirements for all MH/SUD benefits.
- Plans with
medical management programs delegating their review authority to
physicians for medical/surgical benefits but conducting their
own reviews for MH/SUD services.
preauthorization requirements for prescription drugs prescribed
in connection with MH/SUD conditions.
pre-notification of all MH/SUD treatments and inpatient
- Plans that
exclude residential treatment for chemical dependency, impose
geographical limitations related to treatment for MH/SUD
benefits, or require that MH/SUD facilities be licensed by a
state, but do not impose the same restrictions on
imposing a requirement that a beneficiary must first fail to
achieve progress in a non-intensive outpatient treatment before
receiving coverage for intensive outpatient treatment.
- Plans that
only cover services resulting in measurable mental health
improvement within a given timeframe.
requiring a written treatment plan prescribed and supervised by
a behavioral health provider for MH/SUD benefits.
Takeaway for Employers. While the DOL guidance addresses many group
health plan provisions that may cause noncompliance with MHPAEA's
parity requirements, it is not intended to be an exhaustive list of
all plan provisions that may create problems under the MHPAEA. Thus,
group health plan sponsors are advised to:
- Review all
provisions in their group plan that relate to MH/SUD benefits to
ensure that all elements meet the parity requirements under
- Work with
plan sponsors to ensure that their vendors are administering the
group health plan in such a way that the MH/SUD benefits are in
parity with the medical/surgical benefits.
- Consult with
qualified legal counsel to confirm that plan provisions that
relate to MH/SUD benefits are in compliance MHPAEA's parity
- Be ready to
provide evidence that demonstrates parity compliance for any
provision that the DOL has flagged for review.
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