The Genesis of the Mental Health Parity and Addiction Equity Act

Before the Mental Health Parity Act of 1996 (MHPA), health insurance plans were not required to cover mental health care, which made treatment expensive and difficult to access. The MHPA was the first piece of legislation that attempted to resolve this issue. It provided that large group health insurance plans could not impose annual or lifetime caps on mental health benefits that are less favorable than caps on medical or surgical benefits.

However, most health plans soon found other ways to circumvent the requirements of the MHPA. For instance, insurance carriers increased out-of-pocket maximum costs for mental health care or limited the number of covered visits to mental health providers. The MHPA also had an expiration date, although legislators extended it several times through 2007.

When Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008, it represented a substantial victory after decades of fighting for better care for mental health and substance use disorders. However, despite that victory, significant work in this area of healthcare is still needed.

The primary purpose of the MHPAEA was to make it as easy to access care for mental health and substance use disorders as it is for physical illnesses or injuries. Under the MHPAEA, mental health benefits must be not more difficult to access and use than medical or surgical benefits.

MHPAEA applies to plan years beginning October 3, 2009, and later. Although it directly applies only to large-group health plans, it indirectly applies to small-group health plans through the essential health benefit (EHB) requirements of the Affordable Care Act (ACA). The EHB requirements include the following:

  • If a group health insurance plan includes medical/surgical benefits and mental health/substance abuse disorder benefits (MH/SUD benefits), the financial requirements and treatment limitations for MH/SUD benefits must be no more restrictive than those for medical/surgical benefits. These financial requirements and treatment limitations include:
    • Deductibles;
    • Co-pays;
    • Number of visits; and
    • Days of coverage, such as for inpatient care.
  • MH/SUD benefits cannot be subject to separate cost-sharing requirements or treatment limitations that do not apply to medical/surgical benefits.
  • If a group health insurance plan provides benefits for out-of-network medical/surgical care, then it must provide benefits for out-of-network MH/SUD care.
  • Insurance companies must disclose standards for medical necessity determinations and denials of MH/SUD benefits upon request.

In 2013, the U.S. Department of Treasury, Department of Labor, and Department of Health and Human Services published a joint final regulation implementing and clarifying portions of the MHPAEA. This regulation, which took effect in January 2014, requires the following:

  • All cumulative financial requirements in a classification must combine medical/surgical and MH/SUD benefits, including deductibles and out-of-pocket limits.
  • A group health insurance plan may not impose a nonquantitative treatment limitation (NQTL) concerning MH/SUD benefits unless the same standards, processes, or factors are used to impose an NQTL on medical/surgical benefits in a classification. An NQTL is a non-numerical limitation, such as medical management, step therapy, or pre-authorization.
  • All plan standards that limit the scope or duration of benefits for services are subject to NQTL parity requirements, including restrictions on geographic limitations, facility-type limits, and network adequacy.

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 678-439-6236.

The following two tabs change content below.

Hall Benefits Law, LLC

HBL offers employers comprehensive legal guidance on benefits in mergers and acquisitions, Employee Stock Ownership Plans (ESOPs), executive compensation, health and welfare benefits, healthcare reform, and retirement plans. We counsel a wide spectrum of clients including small, mid-sized, and large companies, 401(k) investment advisors, health insurance brokers, accountants, attorneys, and HR consultants, just to name a few. HBL is passionate about advising clients, and we are dedicated to our mission: to provide comprehensive, personalized, and practical ERISA and benefits legal solutions that exceed client expectations.

Latest posts by Hall Benefits Law, LLC (see all)