精神健康平等 Compliance Remains a Key Focus in 2024

联邦政府正在继续努力，在2024年改善获得精神健康和物质使用障碍(MH/SUD)护理的机会, 执行的首要任务是遵守雇主赞助的健康计划的《梅高美集团4858》.

MHPAEA是一项联邦法律，旨在防止提供MH/SUD福利的团体健康计划和健康保险发行机构对这些福利施加比一般适用于可比医疗或手术福利更多的限制. 

美国.S. Department of Labor’s Employee Benefits Security Administration (EBSA) enforces MHPAEA. According to a July 2023 报告 to Congress, EBSA devotes 近25%的执法项目致力于关注MHPAEA非定量治疗限制(nqtl)。. 一般, if violations are found by an EBSA investigator, the health plan must remove any noncompliant plan provisions and pay any improperly denied benefits

行动步骤

Given EBSA’s continued focus on MHPAEA compliance, employers should consider taking the following steps:

• 联系其发行人或第三方管理人(tpa)，确认其健康计划的nqtl已完成比较分析，并已更新以反映2024年的条款和覆盖范围;
• Monitor any new legislation or regulatory guidance on MHPAEA;
• Watch for warning signs of problematic NQTLs, such as fail-first protocols or written treatment plan requirements; and Consider MHPAEA’s parity requirements before making any changes to the plan’s coverage of medical/surgical benefits or MH/SUD benefits.

活动执行

• EBSA conducts MHPAEA compliance reviews in all its investigations where MHPAEA applies.
• When EBSA identifies MHPAEA violations, 它要求该计划对任何不合规的计划条款进行必要的修改，并支付任何不当拒绝的福利索赔.
• EBSA还可能要求计划或服务提供商向可能受影响的参与者和受益人提供通知.

NQTLs

• NQTLs impose nonnumerical limits on the scope or duration of benefits, such as prior authorization requirements, step therapy and provider reimbursement rates.
• 健康计划和发行人必须对用于医疗/外科福利与MH/SUD福利的nqtl进行比较分析.

精神健康平等

MHPAEA是一项联邦法律，它通常防止提供MH/SUD福利的团体健康计划和健康保险发行机构对这些福利施加比医疗和外科保险更不利的限制. MHPAEA generally applies to health plans sponsored by employers with 50人以上. However, due to an Affordable Care Act reform, non-grandfathered health plans in the small group market must provide essential health benefits (which include MH/SUD services) and comply with MHPAEA.

雇主通常依靠他们的运营商或tpa以符合MHPAEA的方式设计和管理他们的MH/SUD福利. However, employers have a 信托责任 to ensure their health plan vendors comply with applicable laws, including MHPAEA. 仔细监控MHPAEA合规性也有助于保护雇主免受EBSA执法行动和参与者诉讼的影响. Employers should maintain documentation showing their due diligence regarding MHPAEA compliance. 除了, 帮助消除精神卫生保健方面不允许的障碍的雇主可能会在劳动力中看到好处, such as a more productive workforce and positive company culture.

奇偶性需求

MHPAEA contains the following parity requirements: 

• 的 financial requirements (比如免赔额, 共同支付, coinsurance and out-of-pocket limits) applicable to MH/SUD benefits cannot be more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits; and
• 治疗的局限性 (such as frequency of treatment, 访问次数, 覆盖天数或覆盖范围或持续时间的其他类似限制)也必须符合MHPAEA的平价要求. 

除了, MHPAEA imposes parity requirements on the NQTLs that plans may place on MH/SUD benefits. NQTLs包括, 例如, medical management standards, formulary designs for prescription drugs, plan methods for determining usual, customary and reasonable charges, exclusions based on a failure to complete a course of treatment, and restrictions based on facility type or provider specialty.

A 拟议的规则 was issued in August 2023 that, 如果最终确定, would make extensive changes to MHPAEA’s requirements, especially those for NQTLs. 求奇偶性, the 拟议的规则 would require health plans and issuers to collect, 与获得医疗/外科医疗保险相比，评估和考虑美高美集团4688获得医疗/外科医疗保险的相关数据，而不是依赖于对保险范围的描述. 拟议的规则还将对与网络组成有关的nqtl实施一项特殊规则，并为比较分析建立额外的标准.

比较分析

MHPAEA requires health plans and issuers to conduct 比较分析 of the NQTLs used for medical/surgical benefits compared to MH/SUD benefits. 的se analyses must contain a detailed, 对有争议的具体计划条款和做法进行书面和合理的解释，并包括计划或签发人美高美集团4688nqtl符合MHPAEA的结论的依据. 计划和发行人必须根据要求向联邦政府或适用的州当局提供比较分析.

根据EBSA, 比较分析“为计划和发行方提供了一个机会，让他们仔细而深入地思考，与医疗/外科福利相比，如何将nqtl应用于MH/SUD福利, either through a longstanding practice or a new limitation.“然而, according to its July 2023 报告, all of the 比较分析 submitted to EBSA during its investigations have been inadequate. 

MHPAEA执法

EBSA enforces MHPAEA’s requirements for private-sector employment-based health plans. EBSA conducts MHPAEA compliance reviews, including for compliance with NQTL requirements, in all its investigations where MHPAEA applies. When EBSA identifies MHPAEA violations in a specific group health plan, it asks the plan to make necessary changes to any noncompliant plan provision and pay any improperly denied benefit claims. EBSA may also require the plan or service provider to provide notice to potentially affected participants and beneficiaries.

EBSA Enforcement Examples

• A large self-funded plan covering over 22,000名参与者排除了用美沙酮治疗阿片类药物使用障碍(必须通过阿片类药物治疗方案提供)，但涵盖了美沙酮治疗医疗/手术条件. 当EBSA要求时，该计划没有进行比较分析，以解决排除美沙酮治疗阿片类药物使用障碍的问题. EBSA issued an initial determination letter citing the plan for imposing an impermissible NQTL. 该计划采取了纠正行动，取消了不允许的排除，重新处理并支付了因排除而被错误拒绝的所有索赔.
• 一项涵盖800多名参与者的自费计划不包括住院治疗设施的MH/SUD福利，但包括医疗/外科住院治疗设施的福利, such as skilled nursing facilities and stroke rehabilitation programs. 当EBSA提出要求时，该计划没有解释覆盖范围的差异，也没有对这种排除进行比较分析. EBSA issued an initial determination letter citing the plan for imposing an impermissible NQTL. 该计划取消了排除并重新处理先前被拒绝的MH/SUD住宅处理索赔.
• A self-funded plan excluded MH/SUD benefits provided via telephone, email or internet. 的 plan did not have any similar restrictions on medical/surgical benefits. EBSA issued an initial determination of noncompliance to the plan, citing the exclusion as an impermissible NQTL. 的 plan removed the impermissible NQTL and notified participants of the change in plan terms.

本合规公告并非详尽无遗，任何讨论或意见也不应被视为法律建议. Readers should contact legal counsel for legal advice. ©2024 Zywave, Inc. 版权所有.