Below are some of the most commonly asked questions by consumers and providers regarding coverage and reimbursement of addiction and mental health services. This document was prepared by the Parity Implementation Coalition, a group of mental health and addiction provider and consumer organizations dedicated to the implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). NAMI is a member of this coalition.
Based on real examples of non-compliant policies, claims data and input from Parity Implementation Coalition members around the country in 2010, this document identifies the most common noncompliance issues by self-insured and other health plans.
Although MHPAEA’s interim final regulations went into effect for plan years beginning on or after July 1, 2010, the law has been in effect since October 2009. While the regulators announced in February that (because the regulations were not out by 1/1/10) plans would only be held to a “good faith compliance effort until the regulations went into effect,” plans ARE required to make their best effort to comply in 2010.
Beginning for plan years beginning on or after July 1, 2010, covered plans who fail to comply with the law are subject to a $100 per member per violation fine.
How to Use This Document
For each of the non-compliance issues, this FAQ document provides a brief description of the non-compliance issues and a description of individual and provider rights under the law. These answers and supporting legal rationale were prepared by a leading health care law firm in Washington, DC - Patton Boggs, LLP.
This FAQ document is being made available to you as a tool in helping you file requests for coverage and appeals of adverse benefit determinations. You should identify the examples that relate to MHPAEA non-compliance issues faced by your members/organizations and use only the rationale that addresses your specific compliance concerns.
A companion to this legal analysis will follow in approximately a month. The companion piece will supplement this analysis by providing simple, easy to use sample requests for coverage and appeals letters and winning tactics to help increase the prospects for a successful appeal of an adverse benefit determination.
If you have questions or concerns about MHPAEA compliance issues not addressed in this document, please feel free to e-mail me. To access this document and for more information about parity and the Parity Implementation Coalition, please visit www.mentalhealthparitywatch.org.
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