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Life Health > Health Insurance > Health Insurance

EBSA: Parity Lets Plans Set Office Visits Apart

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The Employee Benefits Security Administration and other federal agencies have put out guidance on how to interpret part of the Mental Health Parity and Addiction Equity Act (MHPAEA).

The Mental Health Parity Act of 1996 already requires employers with more than 50 employees that offer mental health benefits to use the same total lifetime and annual benefits limits for mental health care and general medical care.

The MHPAEA goes further. It will prohibit employer-sponsored health plans with more than 50 participants that offer mental health benefits from “applying any financial requirement or treatment limitation to mental health or substance abuse disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation applied to substantially all medical/surgical benefits in the same classification.”

In January, EBSA, the Internal Revenue Service and the Centers for Medicare and Medicaid Services released interim final regulations implementing the statute. The regulations take effect today. At employer health plans with plan years that start Jan. 1, benefits managers will have to incorporate the new parity rules Jan. 1, 2011.

“Since the interim final regulations were issued, some plans and issuers have stated that it is common with respect to outpatient benefits for plans and issuers to require a copayment for office visits (e.g., physician or psychologist visits) but coinsurance for other outpatient services (e.g., outpatient surgery, facility charges for day treatment centers, laboratory charges, or other medical items),” EBSA officials say in the new batch of MHPAEA guidance.

Commenters have asked EBSA whether, for purposes of determining parity for outpatient benefits, a plan or insurance issuer can establish any sub-classifications for types of service.

While the agencies are developing the final regulations, they will establish an “enforcement safe harbor,” EBSA officials say.

The agencies will not take enforcement action against a plan or issuer that divides its outpatient benefits into two sub-classifications – office visits and all other outpatient items and services — for purposes of applying the financial requirement and treatment limitation rules under the MHPAEA, officials say.

“After the sub-classifications are established, the plan or issuer may not impose any financial requirement or treatment limitation on mental health or substance use disorder benefits in any sub-classification (i.e., office visits or non-office visits) that is more restrictive than the predominant financial requirement or treatment limitation that applies to substantially all medical/surgical benefits in the sub-classification using the methodology set forth in the interim final rules,” officials say.

Under the MHPAEA rules, separate sub-classifications for generalists and specialists are not permitted, officials say.


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