Compliance

The Affordable Care Act (ACA) presents many new compliance challenges that range from ensuring plan designs incorporate the required benefits to notifying employee’s about the public Exchange.

Mental Health Parity

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Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA), group health plans providing both medical benefits and mental health and substance use disorder benefits must offer such benefits in parity.  The MHPAEA does not mandate the coverage of mental health and substance use disorder benefits but it does require plans offering those benefits to do so in parity with any medical or surgical benefits offered under the plan.

Parity for Financial Requirements and Treatment Limitations

Group health plans may not apply any financial requirement (e.g., deductibles, co-payments, co-insurance and out-of-pocket maximum) or treatment limitation (e.g., frequency of treatments, number of visits or days of coverage) to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation that is applied to substantially all medical/surgical benefits in the same classification.

Classifications of benefits are defined to include:  (1) inpatient in-network; (2) inpatient, out-of-network; (3) outpatient, in-network; (4) outpatient, out-of-network; (5) emergency care; and (6) prescriptions drugs.

A financial requirement is considered to be predominant if it applies to more than one-half of the medical or surgical benefits in a classification.  In general, a financial requirement or treatment limitation is considered to apply to substantially all medical or surgical benefits in the classification if it applies to two-thirds or more of the benefits.

These requirements are effective on the first day of the plan year that starts on or after July 1, 2014.  Plan sponsors offering mental health and substance use disorder benefits should review their plans to ensure compliance with the MHPAEA.