Mental Health Parity and

Addictions Equity Act of 2008 (MHPAEA)

Interim Final RulesSpring 2010

Mental Health Parity and

Addictions Equity Act of 2008 (MHPAEA)

Interim Final RulesSpring 2010Edward Jones, PhD

Paul Rosenberg, JD

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When? Who?

• Effective for covered plans with plan years beginning on or after July 1, 2010.

• Issued jointly by IRS, DOL, and CMS.• Covers federally regulated ERISA plans and state-regulated

insured plans.• Medicaid managed care plans will be covered by separate rules

issued solely by CMS. • Excluded plans are those under 50 employees, those that

utilize a complex cost opt-out after year one, government employee plans that opt out, and Medicare.

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Key Provisions

• Cumulative treatment limitations – As provided in the 1996 Act, separate but equal annual and lifetime limits

remain permissible. Other cumulative treatment limitations, i.e., deductibles and out-of-pocket maximums, must be combined.

• Six benefits classifications are created– Inpatient, in-network and out-of-network– Outpatient, in-network and out-of-network– Emergency care– Prescription drugs

• Medical and MHSA parity is measured within each classification– This provision impacts “carved-out” and “carved-in” plans equally. – Out-of-network MHSA coverage must be equivalent to the medical coverage

in each benefits classification. This increases the value of ValueOptions® large provider network.

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• Limited pre-emption of state law– State laws that mandate more coverage (e.g., $36k/year autism mandate in

PA) or less restriction (e.g., New York’s utilization review law) control. However, ERISA exemption remains intact.

– For state insurers governed by state laws, MHPAEA then removes the cap from such state mandates, unless the rule is clarified.

• Co-payment differentials – MHSA office visits must be assigned the lowest relevant co-payments, i.e.,

“primary care” vs. “specialty.” Plans that can demonstrate that a higher co-payment is “predominant” in the medical benefit may apply it to MHSA.

• EAP as gatekeeper– Plans may not require members to utilize an EAP before accessing MHSA

benefits unless a similar requirement applies to medical-surgical benefits. Nonetheless, the incentive to promote EAP use remains intact.

Key Provisions, cont’d

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• Non-quantitative treatment limitations– Non-quantitative treatment limitations, including medical management and

establishment of reasonable and customary rates, must be applied “no more stringently” to MHSA than to medical-surgical benefits. Variations are permissible “to the extent that clinically recognized appropriate standards of care may permit a difference.”

• Alternate levels of care – The rules defer regulation of levels of care that exist only for MHSA

treatment (e.g., day treatment, RTC). It is likely that ALOC services will ultimately be regulated. ValueOptions® recommends careful medical management of these services.

Key Provisions, cont’d

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Next Steps

• Review medical and MHSA benefit plans to perform parity comparison and document rationale for both benefit and clinical policy decisions.

• ValueOptions® will establish accumulator exchange process with medical plan at no cost.

• ValueOptions® will continue to work with the Association for Behavioral Health and Wellness (our trade association group) to further understand the thinking and next steps by regulators.

Questions

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