Officials at the Employee Benefits Security Administration (EBSA) are trying to plug any loopholes employers and plans might try to use to distinguish between behavioral health benefits and general medical benefits.
The officials at EBSA, an arm of the U.S. Labor Department, have given hole-plugging answers in a batch of guidance concerning the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
MHPAEA supplements an earlier mental health parity law enacted in 1996.
Both laws affect only employers that choose to offer behavioral health benefits along with other medical benefits.
The 1996 law required behavioral health and other medical benefits to be similar. The new law imposes more detailed parity rules, and plans that violate the MHPAEA parity requirements could face fines of up to $100 per enrollee per day.
Plans may be able to impose some differences when “recognized clinically appropriate standards of care may permit a difference,” officials say.
But, in the new guidance, officials say a plan may not require a utilization reviewer to determine that a mental health or substance abuse treatment is medically necessary unless the plan also requires a medical necessity review for medical and surgical care.
Requiring a medical necessity review only for behavioral health care, “violates MHPAEA’s prohibition on separate treatment limitations that are applicable only to mental health or substance use disorder benefits,” officials say.
A plan cannot routinely approve 7 days of inpatient care for general medical problems and just 1 day of inpatient care for behavioral health problems, but, if a plan uses an orderly evidence-based process to set specific utilization review standards for many types of care, including behavioral therapy, that might be allowed, officials say.
If a plan requires preauthorization for a few types of general medical care but all types of behavioral care, EBSA officials might view that kind of design with skepticism, officials say.