Here Comes The Rain: Employers Offering Mental Health Benefits Should Prepare For More Scrutiny

Employers can expect some challenging information requests about the mental health and substance abuse benefits offered to employees and their dependents through group health plans, if a draft form released by federal regulators is any indication.

The form—which was included as part of an FAQ issued on June 16, 2017, by the U.S. Department of Labor (DOL), U.S. Department of Health and Human Services (HHS), and U.S. Department of the Treasury—is designed to help plan participants, healthcare providers, and others exercise their rights related to mental health and substance use disorder benefits under the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

Employers could receive these information requests directly, though they would likely be routed to third-party administrators or insurers in most cases. The federal agencies are accepting comments from employers and others on the model form until September 13, 2017.

Only three pages long, the model form focuses on one of the more complicated aspects of the MHPAEA: its rule against applying nonquantitative treatment limitations (NQTLs), such as process or evidentiary standards, more stringently to mental health and substance use disorder benefits than they are applied to medical or surgical benefits. (The form does not cover quantitative limits such as caps on office visits or counseling sessions.) Participants could use the form before receiving treatment or as part of an effort to challenge a claim denial related to those limits.

By filling out the simple form, participants would be requesting that a plan:

provide the specific plan language regarding the limitation and identify all of the medical/surgical and mental health and substance use disorder benefits to which it applies in the relevant benefit classification; identify the factors used in the development of the limitation and the evidentiary standards used to evaluate the factors; identify the methods and analysis used in the development of the limitation; and provide any evidence to establish that the limitation is applied no more stringently, as written and in operation, to mental health and substance use disorder benefits than to medical and surgical benefits. This is certainly more information than has typically been sought about mental health and substance use disorder benefits and may be more information than plans or third-party administrators would typically provide even...

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