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Parity regulations released

January 29, 2010
by Dennis Grantham, Senior Editor
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Americans with mental health/substance abuse disorders gain greater access to affordable care

In a Friday morning teleconference, the Obama Administration announced the release of interim final regulations for implementing the Wellstone Domenici Mental Health Parity and Addiction Equity Act of 2008. The regulations, now open for public comment through May 3, apply to all ERISA plans that cover 50 or more employees that provide mental health/substance abuse benefits, as well as plans provided under the Public Health Service Act. Additional regulations affecting Medicaid Managed care plans are not yet completed, but will be forthcoming from the Center for Medicaid Services (CMS).

Under the long-awaited regulations, Americans with mental health and substance use disorders who are covered by group insurance plans with 50 or more workers should enjoy greater access to care and be better able to afford the care they need. They will no longer be subject to higher co-payments, higher deductibles, or stricter limits on treatments than those that apply to the medical/surgical benefits under their insurance plans.

Parity highlights
The new regulations apply to six categories of benefits, meaning that if a plan offers mental health/addiction treatment benefits, they must be provided in all of the following classifications in which medical/surgical benefits are provided:

• Inpatient- in network;
• Outpatient-in network;
• Inpatient-out of network;
• Outpatient-out of network;
• Emergency; and
• Prescriptions.

Within each of the six classifications, regulators stated that the financial requirements that apply to mental health/substance abuse benefits “cannot be more restrictive than the requirements or conditions that apply to substantially all medical/surgical benefits in the same classification unless recognized, generally accepted standards of care would permit such a difference.”

Addressing fears from advocates about the potential for “separate” deductibles under the law, the regulations say that cumulative financial requirements, including deductibles and out-of-pocket limits, must be “integrated” between medical/surgical and mental health/addiction treatment. No separate deductibles will be allowed.

The new regulations also generally prohibit limitations on the quantity of treatment provided (i.e., the number of visits allowed in a given period), as well as limits based on non-qualitative factors such as:

• Medical management practices;
• Prescription drug formularies;
• Provider admission standards;
• Methods used to develop UCR charges;
• “Fail first” or “step therapy” protocols;
• Failure to complete a course of treatment; or
• Permanent exclusion of all benefits for a particular condition or disorder.

At this time, questions remain about how far current or yet-to-be released regulations will go in defining criteria for medical necessity and the scope of services applicable for mental health/substance abuse treatment under parity. While advocates are encouraged by what they’ve seen so far, lingering concerns about the ability of regulations to address the full range of “aggressive” medical management practices used by plans to limit treatment options and coverage still remain.

Text of the interim final rules for implementation of the Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008 can be found at http://www.federalregister.gov/OFRupload/OFRData/2010-02167_PI.pdf.

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