Mental health benefits: New compliance checklist for firms

If you have some lingering questions about what’s required of employers for mental health benefits under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the DOL’s updated self-compliance tool can help.

On Oct. 23, the DOL released a 39-page downloadable document that provides compliance examples and best practices. It also offers “warning signs” to help employers meet the standards for mental health coverage.

The DOL’s update was also prompted by the 21st Century Cures Act, passed in 2016. Under this Act, the Departments of Health and Human Services and the Treasury are required to issue compliance guidelines every two years. The tool was last updated in 2018.

With the surge in employees’ mental health challenges this year due to the pandemic, the updated tool will help employees “obtain the treatment they need by assisting plans … in complying with the law,” said Secretary of Labor Eugene Scalia.

Parity in deductibles, co-pays

Under the MHPAEA, employers (with more than 50 employees) must ensure their mental health and substance-use disorder benefits are comparable to their medical and surgical benefits. The law requires parity in deductibles and co-pays, as well as the number of covered visits.

There have been more than 100 lawsuits in the past few years alleging employers lacked parity with their mental health benefits. They challenged their health plans coverage for length of benefits, prior authorizations and provider-network standards. The DOL took action against employers that imposed annual office visit limits and a medical-necessity review only on mental health benefits.

Employers can easily spot such cost-sharing discrepancies on benefits communications. Self-insured employers might consider conducting periodic claims reviews to avoid such inequities.

Mental health plan guidelines

The new DOL tool, which enforces the MHPAEA rules, includes the following guidelines:

Classification of benefits. There are six classifications of health benefits: inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-of-network; emergency care; and prescription drugs. These same classifications must be included in the medical plan and the mental health plan.

Prescription drug coverage. If a health plan follows recommended dosages for drugs that treat medical conditions, it must follow the same guidelines for treating mental health and substance use disorders with prescription drugs. For example, a plan excluding prescription drugs for a certain mental health disorder, such as bipolar disorder, isn’t a violation if it also excludes all other benefits for that particular condition.

Experimental treatment. A plan can’t limit or exclude experimental treatment for mental health disorders, but those same restrictions don’t apply to experimental treatment for medical conditions. For example, if someone with chronic depression is referred for an experimental outpatient treatment, the plan must use the same criteria to deny or approve the treatment as it does for medical treatments (FDA approval, same number of trials, etc.).

Network providers. Employers must take comparable measures to help ensure there’s an adequate network of mental health providers
in the plan’s network.

Residential treatment. A health plan that covers room and board for inpatient medical/surgical care, including skilled nursing facilities and other intermediate levels of care, can’t restrict room and board for mental health residential care. The plan would need to include intermediate levels of care for mental health benefits comparably with medical inpatient treatment.