Psychologists, psychiatrists and other behavioral health providers are now trying to get deeply into the inner recesses of the minds — of the people who decide whether or not their services are medically necessary.
The dispute could be enough to fill some health insurance agents and brokers with anxiety.
Regulators at the U.S. Department of Labor, the U.S. Department of Health and Human Services (HHS), and the U.S. Treasury Department set off the war over medical necessity disclosure earlier in November 2013, when they drafted a set of answers to frequently asked questions (FAQs).
The batch of FAQ answers — PPACA FAQ answers Part XVII — deals with how implementation of the Patient Protection and Affordable Care Act of 2010 (PPACA) meshes with implementation of another major health reform law, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
The MHPAEA requires any individual policy or large group health plan that covers mental health services to offer the mental health benefits using the same financial requirements and treatment limitations they use for “substantially all” medical and surgical benefits.
Kathleen Sebelius, the previous HHS secretary, approved regulations that apply the MHPAEA parity rules to individual and small group policies.
In the FAQ Part XVII answers, regulators tried to make the MHPAEA rules more enforceable by requiring administrators of mental health treatment benefits to make the reasons for any benefits denial, and the criteria for deciding whether services are medically necessary, available upon request.
The regulators said the internal appeals and external review provisions in PPACA require plans subject to both PPACA appeal rules and the MHPAEA parity requirements to make all relevant documents and records available to a patient — or a provider acting on a patient’s behalf — free of charge. Regulators said another law, the Employee Retirement Income Security Act (ERISA), requires plans and administrators to provide information on the criteria for decisions about medical necessity within 30 days after the information is requested.
The regulators asked for comments on their answers and have just recently posted the comments on the Web.
Provider and patient groups fear the medical necessity disclosure rules are too lose.
Insurers and mental health benefits managers worry the rules will be a nightmare for the plans and administrators.
For more about some of what the commenters said in their comments, read on.
1. The insurers and administrators wonder how much time and money they’ll have to spend opening windows onto their decision-making processes.
Pamela Greenberg, president of the Association for Behavioral Health and Wellness (ABHW) — wrote to say members of her group believe regulators expanded the MHPAEA when they set out MHPAEA medical necessity disclosure requirements in the MHPAEA final rule.
The ABHW represents many major behavioral health plan companies, including the behavioral health units of Aetna, Cigna and UnitedHealth.