January 29, 2010

By Michael Velardo
Detroit Substance Abuse Examiner

The Mental Health Parity and Addiction Equity Act of 2008 interim rules were issued by the Obama administration and showcased on January 29, 2010.

The law is officially known as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. The law essentially requires employer-sponsored health plans to provide coverage for addiction and mental illness on a level consistent with other health problems.

Summary of MHPAEA Protections according to the U.S. Health and Human Services:

"The Mental Health Parity Act of 1996 (MHPA) states that a group health plan may not impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on medical surgical benefits.

MHPAEA preserves the MHPA protections, and adds significant new protections. Although the law requires "parity", or equivalence, with regard to annual and lifetime dollar limits, financial requirements and treatment limitations, MHPAEA does NOT require large group health plans and their health insurance issuers to include MH/SUD benefits in their benefits package. The law's requirements apply only to large group health plans and their health insurance issuers that already include MH/SUD benefits in their benefit packages.

Key changes made by MHPAEA, which is generally effective for plan years beginning after October 3, 2009, include the following:

• If a group health plan includes medical/surgical benefits and mental health benefits, the financial requirements (e.g., deductibles and co-payments) and treatment limitations (e.g., number of visits or days of coverage) that apply to mental health benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits;

• If a group health plan includes medical/surgical benefits and substance use disorder benefits, the financial requirements and treatment limitations that apply to substance use disorder benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits;

• MH/SUD benefits may not be subject to any separate cost sharing requirements or treatment limitations that only apply to such benefits;

• If a group health plan includes medical/surgical benefits and mental health benefits, and the plan provides for out of network medical/surgical benefits, it must provide for out of network mental health benefits;

• If a group health plan includes medical/surgical benefits and substance use disorder benefits, and the plan provides for out of network medical/surgical benefits, it must provide for out of network substance use disorder benefits;

• Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD, must be disclosed upon request;

• The MHPA parity requirements under existing law (regarding annual and lifetime dollar limits) continue and are extended to substance use disorder benefits."

There are three exceptions to the MHPAEA coverage according to HHS:

• MHPAEA requirements do not apply to small employers who have between 2 and 50 employees;

• Large group health plan sponsors that meet the requirements stated in the MHPAEA download below (Section 512(a)(2) Cost Exemption) and demonstrate that compliance with MHPAEA increases their claims by at least two percent in the first year (one percent in subsequent years) may request exemption from the MHPAEA based on their cost exemption. Subsequently, the plan sponsors may notify the plan beneficiaries that MHPAEA does not apply to their coverage; and

• A nonfederal governmental employer that provides self-funded group health plan coverage to its employees (coverage that is not provided through an insurer) may elect to exempt its plan (opt-out) from the requirements of MHPAEA by following the Procedures & Requirements posted on the Self-Funded Nonfederal Governmental Plans webpage (see Related Links Inside CMS), then issuing a notice of opt-out to enrollees at the time of enrollment and on an annual basis. Thereafter, the employer must also file the opt-out notification with CMS."

The effective date of the final rules will be on April 5, 2010, and apply to insurance plan years that start on or after July 1, 2010.

"Administration officials estimate that 150 million Americans are covered by employer-provided health plans, 90 percent or more of which currently include addiction and mental-health benefits and thus would be subject to the Wellstone law," according to Join Together.

The MHPAEA law

HIPAA

"Medicare and Medicaid are not issuers of health insurance. They are public health plans through which individuals obtain health coverage. Medicaid Managed Care plans, however, are subject to the MHPAEA requirements. Contact your specific Medicare or Medicaid contractor to discuss your level of benefits," according to the U.S. Department of Health and Human Services.

SAMHSA advisory

This Act, and the rules that define it, are something that people in America have needed for a long time. Hopefully, the intent of the Act will live up to its expectations, and provide those with these conditions treatment that is neither compromised, or limited in nature.

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Stuart Smith Elected to Faces & Voices of Recovery Board of Directors

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