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Warning signs that trigger a violation of mental health parity

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as amended by the Affordable Care Act, requires that group health plans and insurers in the group and individual markets ensure that financial requirements and treatment limitations on mental health and substance use disorder (MH/SUD) benefits are no more restrictive than requirements and limitations imposed on medical and surgical benefits. This prohibition applies both to quantitative (numerical) limitations, like visit limits, and to non-quantitative (NQTL-non-numerical), treatment limitations such as pre-authorization requirements.

On June 1, 2016, the departments of HHS and Labor issued a fact sheet listing plan provisions identified as “warning signs” that should “trigger careful analysis” to compare terms applied to medical/surgical coverage to determine whether a violation of the MHPAEA might be present.

Briefly, the listed terms include:

  1. Pre-authorization and pre-service notification requirements, including blanket preauthorization requirements for all MH/SUD services, treatment facility preauthorization requirements not applied to medical/surgical services, or more stringent medical necessity review or prescription drug preauthorization requirements or extensive pre-notification requirements than those applied to medical/surgical services;
  2. Fail-first protocols, requiring an individual to fail to achieve progress with a less intensive form of treatment before a more intensive form is covered;
  3. Probability of improvement requirements, for example, offering coverage of continuing treatment only if improvement is demonstrated or probable;
  4. Written treatment plans, requiring treatment plans completed by specified professionals, within a certain time, or on a regular basis where similar requirements are not applied equally to medical/surgical coverage;
  5. Other limits or exclusions, including:

    • Excluding chemical dependency services in event of noncompliance,
    • Excluding coverage for residential treatment,
    • Geographical limitations on MH/SUD services not imposed on medical and surgical services, or
    • Facility licensure requirements not imposed on medical/surgical facilities.

The OPPA will be meeting again with representatives of the Ohio Department of Insurance to share concerns about monitoring and enforcement of MHPAEA. OPPA members who suspect a possible violation of MHPAEA by a health insurance company in Ohio should contact Janet Shaw, OPPA Executive Director.

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