New FAQs and Module Disclosure Form Continue to Clarify Compliance Requirements

On September 5, 2019, the U.S. Departments of Labor, Health and Human Services and Internal Revenue Services finalized Frequently Asked Questions (FAQs) that provide additional insights on the nonquantitative treatment limitations (NQTL) requirements of the Mental Health Parity and Addiction Equity Act of 2008 (Federal Parity Law).

Background

Since the adoption of the Federal Parity Law, the federal agencies have published several rounds of FAQs to help provide a framework for insurers to become parity compliant. Most of the previous FAQs are listed with hyperlinks on the Parity Implementation Coalition’s website, and can be accessed here.

As a cornerstone of the Federal Parity Law, insurers must meet specific requirements in terms of how mental health and substance use disorder (MH/SUD) benefits are covered and paid for in comparison to medical/surgical benefits. To learn more about the Federal Parity Law requirements, The Kennedy Forum has published some helpful information on its FAQ page.

The New FAQs

The new FAQs published last month provide additional insights on how insurers can be parity compliant through 11 specific scenarios. In particular, several NQTL and disclosures examples address:

• Experimental treatment exclusions
• The ranking of medical evidence to justify coverage
• Permissible dosage limits and exclusions for prescription medications
• Step therapy and fail-first policies
• Proper methods to establish provider reimbursement rates
• Insights on network adequacy protocols
• Ways to promote appropriate plan disclosure
• The need to keep a health plan’s online provider directory up to date

Although FAQs do not establish any new requirements per se, they do reference several specific MH/SUD conditions, including autism, eating disorders, and substance use disorders. The FAQs also showcase examples of insurer processes that are—and are not—in compliance with the Federal Parity Law.

Model Disclosure Form

In addition, the Model Disclosure Form (starting on page 16 of the FAQ document) is designed to be used by consumers to gain a better understanding of how their health plan is covering MH/SUD benefits in comparison to medical/surgical benefits. The form allows people to request both general information, such as the insurer’s prior authorization policies, and specific information, such as the medical necessity criteria that was used to deny a claim.

The Model Disclosure Form incorporates the use of the “six-steps” methodology that was first introduced by The Kennedy Forum, the American Psychiatric Association, and the Parity Implementation Coalition in 2017.

An overview of the six-step compliance process is highlighted in the infographic. The new Model Disclosure Form leverages this approach by empowering consumers to ask their insurers to:

• Provide specific plan language regarding key MH/SUD limitation(s) in part by identifying the medical/surgical and mental health or substance use disorder benefits.
• Identify the factors used in the development of the limitation(s).
• Identify the sources (including any processes, strategies, or evidentiary standards) used to evaluate the factors.
• Identify the methods and analysis used in the development of the limitation(s).
• Provide any evidence and documentation to establish that the limitation(s) is applied no more stringently, as written and in operation, to mental health and substance use disorder benefits than to medical and surgical benefits.

(See FAQs pages 20-21).

Navigating Parity

Although the FAQs and The Model Disclosure Forum shed additional light on key aspects of the Federal Parity Law, much of its regulatory framework remains difficult for consumers and others to understand.  Resources are available to better explain how the Federal Parity Law impacts insured individuals depending on what type of coverage they have and where they live. See the “Resources” pages on www.parityregistry.org, which lists key regulatory and other information by state, and www.paritytrack.org, which includes information on how to file an appeal and more.

Taking the time to understand patient rights and insurer obligations will go a long way in helping to ensure proper access and coverage for MH/SUD treatment.