The U.S. Department of Labor (DOL), U.S. Department of Health and Human Services (HHS), and the Internal Revenue Service (IRS) recently released their 2024 Mental Health Parity and Addiction Equity Act (MHPAEA) Report to Congress. DOL also released its FY 2023 MHPAEA Enforcement Fact Sheet. The Consolidated Appropriations Act, 2021, provides for an annual report specific to nonquantitative treatment limitation (NQTL) comparative analyses and the MHPAEA requires a biennial report by these agencies.
The purpose of the MHPAEA is to ensure that insurance plans provide equal financial requirements and treatment limitations for mental health conditions and substance use disorders as they do for medical/surgical benefits. The Employee Benefits Security Administration (EBSA) and the Centers for Medicare & Medicaid Services (CMS) have the legal duty to enforce MHPAEA. EBSA enforces MHPAEA with respect to employment-based group health plans, and CMS enforces the law with respect to non-federal governmental plans.
MHPAEA Investigations
EBSA investigated 102 health plans in FY 2023. Fifty-one of those investigations involved compliance of plans or service providers with MHPAEA, and more of those investigations occurred concerning self-insured plans than fully insured plans.
Likewise, CMS investigated five health plans for MHPAEA compliance in FY 2023. All these plans were self-funded non-federal governmental plans.
MHPAEA Violations
In 17 investigations, EBSA found 31 MHPAEA violations. The violations included ten involving financial limits, four QTLs, 16 NQTLs involving eight separate treatment limitations that were benefit exclusions, and one final determination of noncompliance with NQTL comparative analysis requirements.
On the other hand, CMS found two MHPAEA violations. One concerned prior authorization for ABA therapy that was more stringent than those required for medical/surgical services. The other violation involved one QTL related to a more stringent financial requirement for mental health and substance abuse disorder treatment, as opposed to medical/surgical treatment.
Results of MHPAEA Enforcement
The report to Congress highlights some major changes that came out of MHPAEA enforcement efforts. For instance, one service provider removed a limitation on the number of visits for autism spectrum disorder therapies, which affects over 15 million participants in 52 different plans. Likewise, MHPAEA enforcement efforts resulted in the $34,000 reimbursement of excess cost-sharing for mental health and substance use disorder benefits, and a $19,000 coinsurance reimbursement for mental health drugs not prescribed by a psychologist or neurologist. Other enforcement efforts impacted restrictions on substance use disorder treatment, nutritional counseling for eating disorders, impermissible coinsurance rates and precertification for outpatient mental health and substance abuse treatment, and inflated copayments for in-network mental health treatment.
Priorities for MHPAEA Enforcement
EBSA identified six priority areas that make up most NQTLs reviewed, including the following:
- Prior authorization requirements for inpatient services;
- Concurrent care review for outpatient services;
- Standards for provider admission to participate in a network;
- Out-of-network reimbursement rates and methods for determining usual, customary, and reasonable charges;
- Impermissible exclusions of key treatments for mental health conditions and substance use disorders; and
- Adequacy standards for mental health and substance use disorder provider networks.
MPHAEA Regulations
The agencies also highlighted their release of MPHAEA regulations in 2024, which are geared toward strengthening MPHAEA requirements. The regulations also seek to improve comparative analyses. However, at least one lawsuit is pending as to the legality of the final regulations.
Future Guidance
In their report, the agencies state their intention to provide future guidance on the type, form, and manner of collection and evaluation of required NQTL-related data. They intend the guidance to provide examples of data, an updated MHPAEA self-compliance tool, and a sample comparative analysis with commentary.
HBL has experience in all areas of benefits and employment law, offering a comprehensive solution to all your business benefits and HR/employment needs. We help ensure you are in compliance with the complex requirements of ERISA and the IRS code, as well as those laws that impact you and your employees. Together, we reduce your exposure to potential legal or financial penalties. Learn more by calling 470-571-1007.
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