The Departments of Health and Human Services, Education, Labor and Treasury today released interim final rules providing guidance on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. The regulations are available online.
At first glance, the regulations – which are Interim Final with a comment period – appear to be a huge victory for consumers and families.
The regulations adopt a robust standard for medical-surgical benefits that mental health benefits must be comparable to – specifically, “predominant” and “substantially all” of medical-surgical coverage. In addition, the regulations include comprehensive definitions of treatment limits and financial limitations for which parity is required.
Importantly, the regulations provide new standards with respect to equitable coverage for “non-quantitative” treatment limits, which are defined in the regulations as medical management, drug formulary design, step therapy, “fail first” policies and exclusions from coverage based on failure to complete a course of treatment. This means that the standards for equitable coverage will apply to discriminatory application of medical management techniques as applied to mental illness treatment -- a tremendous victory for consumers and families.
It is important to note that these interim final rules regulations are not the last word implementation of the new parity law. A separate guidance is expected soon from the Centers for Medicare and Medicaid Services (CMS) to states on how the law will apply to Medicaid managed care plans. Furthermore, additional guidance is expected later on the law’s allowance for a cost increase exemption.
Effective Date: This IFR goes into effect on April 5 and will apply to group health plans with plan years starting on July 1 or later. Those plans that were charged with compliance for a plan year that began on January 1, 2010 will be given a good faith exception for compliance with the regulations until July 1.
Scope of Service: The IFR divides benefits into six classifications:
1. Inpatient, in-network
2. Inpatient, out-of-network
3. Outpatient, in-network
4. Outpatient, out-of-network
5. Emergency care
6. Prescription drugs
Within each classification, if a plan provides MH/SU benefits, those benefits must be provided at parity with the medical/surgical benefits provided in that classification.
In addition, the Departments are encouraging public comments on whether and to what extent the Parity Act addresses scope of services or continuum of care provided by insurance plans (information about how to submit public comments is included in the IFR).
Cumulative Financial Requirements: The IFR prohibits plans from instituting separate deductibles, copayments, and out-of-pocket limits for MH/SU and medical/surgical benefits. Any deductibles, copayments, and out-of-pocket limits required by the plan must be integrated and cumulative for all services.
Tracking Implementation of the New Law: Going forward NAMI will be putting in a place a webpage to track information from consumers and families on how the new law is working. This information is critical to informing policymakers in Congress and the Obama Administration on additional steps that may need to be taken to strengthen the law and ensure adequate enforcement. In addition, it is critical for NAMI to demonstrate to the larger public that parity is making a real difference in improving coverage of mental illness treatment and expanding access to critical medical services for children and adults living with mental illness. Among the key issues that need to be tracked:
- Are health plans still imposing an arbitrary limit on covered inpatient days or outpatient visits for behavioral health coverage?
- Are group health plan applying a separate lower deductible or higher cost sharing for outpatient mental health services?
- Have you noticed improved coverage for mental illness treatment in your group health plan in 2010, e.g. lower cost sharing, a lower deductible or elimination of a treatment limitation such as a cap on outpatient visits?
- Are group health plans still using a separate deductible that applies only the plan’s behavioral health benefit? If so, they are likely doing so in violation of the new parity law.
Finally, it should be noted that the Secretaries of HHS, Labor and Treasury went to extraordinary lengths to get these regulations through the development process in their agencies and cleared by the Office of Management and Budget (OMB). NAMI is extremely grateful to Secretary Sebelius, Secretary Solis and Secretary Geitner for their efforts -- and to key allies in Congress that maintained pressure on these agencies to get regulations published in a timely fashion. The regulations will be formally published in the Federal Register on February 2. Comments on the regulations are due May 3. NAMI National will be submitting comments and developing model comments for NAMI affiliates to submit as well. If you have any questions, please feel free to contact me at email@example.com
View NAMI’s comments that were submitted to the agencies this past spring on a Request for Information on issues related to the implementation of parity.