The Mental Health Parity and Addiction Equity Act of 2008 interim rules were issued by the administration 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.
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. Good-faith compliance period: employers and insurers will have until the first plan year beginning on or after July 1, 2010, to comply with the new regulations.
"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.
Highlights of the interim rules:
• Treatment and financial limits. Mental health and substance abuse plan payment and treatment limits cannot be more restrictive than the predominant limit on “substantially all medical and surgical benefits.” “Substantially all” means at least two-thirds of the medical/surgical benefits in a classification. When a plan has multiple limits (such as different copayments for primary and specialty care), the predominant one is the limit applied to more than half of the medical/surgical benefits. This rule applies to all financial limits, except lifetime and annual maximums, and to all quantitative (number of visits) and non-quantitative (medical management) treatment limits.
• Benefits may not be subject to any separate cost sharing requirements or treatment limitations that only apply to such benefits.
• Shared deductible. Group health plans with deductibles must apply mental health/substance abuse expenses and medical/surgical expenses toward the same deductible. Enrollees cannot have to meet a separate deductible for mental health or substance abuse benefits, even if it is equal to or less than the medical/surgical benefit deductible.
• Parity required within benefit classifications and coverage tiers. The regulations establish six benefit classifications: inpatient (in and out of network), outpatient (in and out of network), emergency care, and prescription drugs. Parity is generally required within those classifications and within coverage tiers (single/family) but not across them.
• 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."
• MHPAEA requirements do not apply to small employers who have between 2 and 50 employees.