Know Your Mental Health & Substance Use Disorder Benefits

Defining Mental Health/Substance Use Disorder benefits (MH/SUD)

42 U.S.C. 300gg-26

42 U.S.C. 18031(j)

45 CFR 146.136(a)

45 CFR 156.115(a)(3)

The policy or contract shall define mental health benefits or substance use disorder benefits to mean items or services for the treatment of a mental health condition or substance use disorder, as defined by the policy or contract or applicable state law. Any condition or disorder defined as not a mental health condition or substance use disorder must be consistent with generally recognized independent standards of current medical practice and applicable state law.

Classifying benefits

42 U.S.C. 300gg-26

42 U.S.C. 18031(j)

45 CFR 146.136(c)(2)(ii)(A)

45 CFR 146.136(c)(3)(iii)(A)

45 CFR 146.136(c)(3)(iii)(B)

45 CFR 146.136(c)(3)(iii)(C)

45 CFR 156.115(a)(3)

The issuer shall assign MH/SUD benefits to each of the six classifications and permitted sub-classifications. The issuer must apply the same standards to medical/surgical benefits and to mental health or substance use disorder benefits in determining the classification or sub-classification in which a particular benefit belongs. The issuer shall demonstrate that mental health or substance use disorder benefits are covered in each classification in which medical/surgical benefits are covered.

Financial requirements and quantitative treatment limitations

42 U.S.C. 300gg-26(a)(3)(A)

42 U.S.C. 18031(j)

45 CFR 146.136(c)(2)(i)

45 CFR 146.136(c)(3)(i)(A)

45 CFR 146.136(c)(3)(i)(B)(1)

45 CFR 146.136(c)(3)(i)(B)(2)

ACA FAQ 34 Q3

45 CFR 156.115(a)(3)

The policy or contract shall not apply any financial requirement or quantitative treatment limitation on mental health or substance use disorder benefits in any classification (or applicable sub-classification) that is more restrictive than the predominant financial requirement or quantitative treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification (or applicable sub-classification).

Cumulative financial requirements and cumulative quantitative treatment limitations

42 U.S.C. 300gg-26(3)

45 CFR 146.136(c)(3)(v)

The issuer shall not apply any cumulative financial requirement or quantitative treatment limitation to mental health or substance use disorder benefits in a classification that accumulates separately from any established for medical/surgical benefits in the same classification.

Nonquantitative treatment limitations (NQTLs)

42 U.S.C. 300gg-26(a)(3)(A)

42 U.S.C. 18031(j)

45 CFR 146.136(c)(4)(i)

45 CFR 156.115(a)(3)

The issuer shall justify the application of any NQTL to mental health or substance use disorder benefits within a classification of benefits (or applicable sub-classification) such that any processes, strategies, evidentiary standards, or other factors used to apply a limitation, as written and in operation, are comparable to, and are applied no more stringently, than the processes, strategies, evidentiary standards, or other factors used to apply the limitation to medical/surgical benefits within the classification (or applicable sub-classification).

NQTLs shall be categorized as such:

1. medical management- which includes issuer prior authorization, concurrent review and retrospective review protocols and the medical necessity criteria utilized in conjunction with them;
2. exclusions of coverage; e.g., experimental or investigational;
3. plan provider network matters- credentialing criteria, network tiering;
4. network adequacy; i.e. plan MH/SUD network performance;
5. provider reimbursement rates;
6. prescription drugs;
7. other NQTLs as identified by the issuer- restrictions on facility type, geographic location.

Disclosure

42 U.S.C. 300gg-26(a)(4)

45 CFR 146.136(d)(1)

45 CFR 146.136(d)(2)

45 CFR 146.136(d)(3)

45 CFR 147.136(b)(2)

45 CFR 147.136(b)(3)

The issuer shall ensure that it complies with all availability of policy or contract information and related disclosure obligations regarding:

1. criteria for medical necessity determinations;
2. reasons for denial of services;
3. information relevant to medical/surgical, mental health, and substance use disorder benefits
4. rules regarding claims and appeals, including the right of claimants to free reasonable access and copies of documents, records and other information including information on medical necessity criteria for both medical/surgical benefits and mental health and substance use disorder benefits, as well as the processes, strategies, evidentiary standards, and other factors used to apply a NQTL with respect to medical/surgical benefits and mental health or substance use disorder benefits under the plan.

Issuer coordination with vendors

78 FR 68250

If the issuer contracts with a managed behavioral health organization (MBHO) to provide any or all of the issuer’s mental health or substance use disorder benefits it shall ensure that it coordinates with the MBHO to secure compliance with MHPAEA.

Documentation of Comparative Analysis for NQTLs

Section 203 of the Consolidated Appropriations Act, 2021 (CAA) amends PHSA —Section 2726(a) of the Public Health Service Act: 42 U.S.C. 300gg–26(a)

Revises ERISA, PHSA, and the tax code to require plans and issuers to conduct comparative analyses to document their compliance with the existing rules governing NQTLs under MHPAEA.

Inpatient hospital benefits

627.668 (2)(a) F.S.

627.668 (2)(b) F.S.

627.668 (2)(c) F.S.