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Mental Health Parity - an overview of the final rule

Mental Health Parity and Addiction Equity Act Final Rule – An Overview

On November 8, 2013, the Department of Health and Human Services (HHS) issued the long-awaited Final Rule (FR) implementing the Mental Health Parity Act.

APA has been advocating for parity for more than 20 years. Overall, we are pleased with the rule, which contains the following significant features:

  • Insurer Transparency – Insurers must provide beneficiaries who ask with the medical necessity standards and the processes used to implement them (e.g. concurrent review, prior authorization) for both mental health/substance use disorder (MH/SUD) and medical surgical claims. This is a significant step forward for mental health patients since before the issuance of the FR many insurers were refusing to provide this information, making it very difficult to determine if there was compliance with the law.
  • Scope of Services – The rule confirmed what APA has long argued – that parity requires a comparable continuum of care for MH/SUD and medical/surgical conditions, which includes intermediate levels of care.
  • Non-Quantitative Treatment Limitations (NQTLs) and Reimbursement Rates – The FR reaffirms that provider reimbursement rates are a form of NQTL. This confirms the APA’s position that provider reimbursement rates are integral to achieving parity and network adequacy. Methodologies used to determine rates must be comparable for providers of medical/surgical and MH/SUD care. Limiting factors may not be more stringently applied to mental health professionals.
  • Mental Health Carve-Outs – Carve-outs are not exempt from compliance with the parity laws. The overall plan providing both the mental health and medical surgical benefits must do so in parity regardless of how it divides up the administration of benefits.
  • Financial Requirements and Quantitative Treatment Limitationsl– The FR reaffirms that quantitative and financial treatment limitations cannot be more restrictive for mental health than the predominant feature that applies to substantially all medical surgical benefits.

Medicaid – The FR does not apply to Medicaid Managed Care or Medicaid Expansion Programs. It is unfortunate that while the law stipulates that parity applies, the issue of parity under Medicaid has not yet been resolved. That said, we are optimistic that the guidance HHS has promised to address this issue will be beneficial to Medicaid beneficiaries who suffer from mental illness and substance use disorders.

States will play an increasingly important role in enforcement and implementation, and APA and District Branches must be at the forefront, providing education and assistance and keeping state officials informed about problems and processes that need resolution.

The road to parity has been lengthy; and the trek is not yet over. As with every rule, “final” is the beginning – there will be disagreements over how to interpret the language and what it all means. Insurers will push the envelope and we have to push it back so that our patients will really see parity now. Over the next few years, APA, MPS, and the other District Branches must continue to work with Federal and State Agencies to ensure complete equity in the health system.

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