The three big federal agencies that oversee health insurance and health plans — the “tri-agencies”  — have posted a new batch of answers to health coverage questions.

Officials from the U.S. Department of Health and Human Services (HHS), the Internal Revenue Service (IRS) and the Employee Benefits Security Administration (EBSA) address a wide range of issues.

  • A federal law, the Women’s Health and Cancer Rights Act of 1998 (WHCRA), requires any health plan that covers mastectomies to pay for breast reconstruction surgery. In the new guidance, the tri-agencies say any plan subject to the WHCRA requirements must pay for nipple and areola reconstruction.

  • If a plan has to pay for a routine colonoscopy, to comply with the Patient Protection and Affordable Care Act (PPACA) preventive services coverage requirements, then the plan also has to pay for colonoscopy-related bowel preparation medications.

  • If a plan uses “reference-based pricing” — a Priceline-style “name your price” system for setting medical procedure costs — then it must make sure enrollees have adequate access to providers who accept the reference price. Otherwise, the tri-agencies will treat the plan that has no provider network.

  • If a cancer patient is getting ordinary chemotherapy and is in a clinical trial for an experimental anti-nausea drug, the plan must pay for the chemotherapy. The plan cannot reject the patient’s chemotherapy claims by saying the ordinary chemotherapy is part of the clinical trial for the anti-nausea drug. 

In still another section of the guidance, which concerns the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the tri-agencies tell a mental health services provider what kinds of information to seek if a plan tries to limit a patient’s access to treatment for depression. 

See also: Feds hint at coming mental parity suits

The MHPAEA parity requirements apply only to the large-group plans and small self-insured group plans that choose to cover mental health care and addiction services treatment. When affected plans choose to cover behavioral health care, any limits on the amount of behavioral care covered must be comparable to the limits on the amount of medical and surgical care covered. Nonquantitative treatment limits (NQTLs), such as requirements that patients get permission from the plan before getting a specific form of care, must also be comparable.

HHS recently finished separate regulations that require individual and small-group care to meet behavioral health care parity requirements.

The patient in the new MHPAEA guidance has coverage from a group plan that’s subject to MHPAEA. The tri-agencies note that their answer applies only to a patient subject to the MHPAEA parity requirements, not to a patient who is eligible for behavioral health benefits because of the new HHS requirements.

But the tri-agencies say a behavioral care provider who is treating a patient with the kind of coverage governed by MHPAEA has a legal right to ask the plan for many different types of data about quantitative treatment limits and NQTLs.

The tri-agencies list six different types of information the provider should consider seeking.

To see the types of information on the list, read on.

Sailboat, represent easy MHPAEA documentation requirement

1. Basic NQTL information requirements.

The tri-agencies say a provider can ask the patient’s plan for:

  • A summary plan description (SPD).

  • The specific plan language explaining why the plan imposed a particular NQTL.

See also: Mental health parity disclosure war: 4 battlefields

 Storm clouds - implying tougher MHPAEA documentation requirements

2. More complicated NQTL information requirements.

The tri-agencies say a provider can ask the patient’s plan for:

  • Information about how the plan would apply the same NQTL to similar types of medical or surgical care. 

  • Any plan analyses that show why the plan believes its NQTL complies with the MHPAEA.

See also: Feds: ERISA plans must share their decision support tools

Flood - to represent hard MHPAEA justification requirements

3. Open-ended NQTL information requirements.

The tri-agencies say the provider can also ask the patient’s plan to provide:

  • “The specific underlying processes, strategies, evidentiary standards, and other factors (including, but not limited to, all evidence) considered by the plan (including factors that were relied upon and were rejected) in determining that the NQTL will apply to this particular [mental health/substance use disorder] benefit.”

  • “The specific underlying processes, strategies, evidentiary standards, and other factors (including, but not limited to, all evidence) considered by the plan (including factors that were relied upon and were rejected) in determining the extent to which the NQTL will apply to any medical/surgical benefits within the benefit classification at issue.”

 

See also:

CMS applies behavioral health parity rules to Medicaid LTC services

Mental parity enforcement fight looms

        

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