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Let’s Go Back to the Basics

This overview of the Mental Health Parity and Addiction Equity Act (MHPAEA) provides a timeline, regulatory provisions, key terms, and analysis of quantitative and nonquantitative treatment limitations. Essential resources for regulators are also included.

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Let’s Go Back to the Basics

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  1. Let’s Go Back to the Basics MHPAEA 101 – HEALTH TRACK Jo-Anne Fameree, Risk & Regulatory Consulting Irvin “Sam” Muszynski, American Psychiatric Association Katie Dzurec, Pennsylvania Insurance Department

  2. Agenda Subtitle 1 • Overview of MHPAEA • Timeline • Regulatory Provisions • Key Terms • QTL and Financial Requirement analysis • NQTL analysis • Resources for Regulators

  3. Overview of MHPAEA Legislative & Regulatory Timeline Oct 3, 2008 MHPAEA passed, amending PHS Act, ERISA, & IRC Feb 2, 2010 Interim Final Rule published • Support for Patients and Communities Act: Oct. 24, 2018 Nov 13, 2013 Final Rule published Jul 1, 2014 Final Rule effective July 1, 2010 IFR effective Oct 3, 2009 MHPAEA effective 2013 2008 2010 2016 2009 2014 Mar 23, 2010 Affordable Care Act Sept 23, 2010 ACA EHB reforms effective Dec 13, 2016: 21st Century Cures

  4. Overview of MHPAEA Essentials The rules are sequential and interrelated • Identify MH/SUD disorder • Identify MH/SUD benefit • Identify med/surg benefit • Classification of MH/SUD and med/surg benefits • Financial requirements & QTL • NQTL – medical necessity, information disclosure • Vendor coordination

  5. Overview of MHPAEA Regulatory Provisions • If a Company provides both med/surg benefits and MH/SUD benefits, then the Company must comply with parity requirements • may not apply any financial requirement or treatment limitation MH/SUD benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all med/surg benefits in the same classification

  6. Overview of MHPAEA Key Terms • Financial Requirements: • Type – deductibles, copayments, coinsurance, or out-of-pocket maximums • Level – the dollar amount or number of visits/sessions • Treatment limitations – limits on benefits based on scope or duration of treatment (e.g., frequency, number of visits, days of coverage) • Quantitative (QTL) – determine whether or to what extent benefits are provided based on accumulated amounts, such as annual or lifetime day or visit limits. Expressed numerically • Nonquantitative (NQTL) – limit the scope or duration of benefits for treatment under a plan or coverage (e.g., prior authorization, formulary design, network)

  7. Overview of MHPAEA Key Terms • MH/SUD Disorder – consistent with generally recognized standards of current medical practice • MH/SUD Benefit – services primarily provided in conjunction with treatment for MH/SUD conditions

  8. QTL and Financial Requirement Analysis For each classification… substantially all and predominant level are based on ratio of expected claims dollar amounts for the covered service to the amounts for ALL covered services YES NO

  9. Outpatient, In-Network classification • Copay - $244,728,384.78/$717,781,326.50 • Coinsurance – • $0/$717,781,326.50 • Deductible – • $206,965,525.50/$717,781,326.50 None of the cost-sharing types meets the substantially all requirement, so no financial requirements can be applied to the MH/SUD outpatient, In-Network classification

  10. Outpatient, In-Network, Office sub-classification Copay meets substantially all for TYPE, so we go to predominant level to see what the maximum amount can be…

  11. NQTL analysis Subtitle 1 NQTLs applied to MH/SUD must be • Comparable to, and • Applied no more stringently Than those applied to med/surg NQTL analysis must be compliant BOTH as written and in operation

  12. NQTL analysis Subtitle 1 • Walk through provisions • Provide examples

  13. MHPAEA Resources for Regulators Subtitle 1

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