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The Wagner Law Group

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 

 

Established 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.

 

 

 

 

Contact Info

The Wagner Law Group

 

  Integrity | Excellence

  

Boston 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110


Palm Beach Gardens 

Tel: (561) 293-3590
Fax: (561) 293-3591
7108 Fairway Drive
Suite 125
Palm Beach Gardens, FL 33418

   

Tampa

Tel: (813) 603-2959

Fax: (813) 603-2961

101 East Kennedy Boulevard

Suite 2140
Tampa, FL  33602 

 

San Francisco

Tel: (415) 625-0002

Fax: (415) 358-8300

300 Montgomery Street

Suite 600

San Francisco, CA 94104

 

St. Louis

Tel: (314) 236-0065

Fax: (314) 236-5743
100 South 4th Street, Suite 550
St. Louis, MO  63102 

 

www.wagnerlawgroup.com

 

 

 

 

June 23, 2016

 

 Health and Welfare Law Alert

 

 

 

New Guidance from DOL on Mental Health Parity and Addiction Equity Act 

 

 

 

The DOL 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 ("MHPAEA").
 
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 med/surgical benefits.

 

 

DOL has 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. 

 

 

DOL 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.

 

 

In 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.

 

 

Some examples of group plan provisions that require further review by plan sponsors (to confirm compliance with MHPAEA's NQTL parity requirements) include the following:

 

  • Blanket 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.
  • Blanket preauthorization requirements for prescription drugs prescribed in connection with MH/SUD conditions.
  • Requiring pre-notification of all MH/SUD treatments and inpatient services.
  • 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 medical/surgical benefits.
  • Plans 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.
  • Plans 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 MHPAEA.
  • 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 requirements.
  • Be ready to provide evidence that demonstrates parity compliance for any provision that the DOL has flagged for review.

 

 

    

 

 

 

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This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.