The DOL, HHS, and IRS have issued a pointed report back to Congress on the pervasive failure by group well being plans to adjust to the Psychological Well being Parity and Habit Fairness Act (MHPAEA). The report is required by the Consolidated Appropriations Act, 2021 (CAA), which expanded psychological well being parity compliance obligations by requiring well being plans and insurers that impose nonquantitative remedy limitations (NQTLs) on psychological well being or substance use dysfunction advantages (reminiscent of restrictions based mostly on facility kind) to carry out and doc (and supply upon request) comparative analyses of the NQTLs’ design and software (see our Checkpoint article). Supposed to fulfill the brand new CAA annual reporting requirement in addition to the present DOL biennial reporting requirement about common MHPAEA compliance, the 2022 report highlights the businesses’ MHPAEA assets and enforcement efforts and particulars the struggles to interpret, implement, and implement the NQTL comparative evaluation requirement. The DOL additionally individually launched its 2021 MHPAEA Enforcement Reality Sheet (see our Checkpoint article).
The report back to Congress emphasizes that well being plans and insurers are failing to ship parity in psychological well being and substance use dysfunction advantages and identifies the highest noncompliant NQTLs. These embrace limitation or exclusion of utilized habits evaluation (ABA) remedy or different companies to deal with autism, restrictive billing necessities, limitation or exclusion of medication-assisted remedy (MAT) for opioid use dysfunction, preauthorization or precertification necessities, and limitation or exclusion of dietary counseling. Between April and October 2021, the DOL requested and acquired NQTL comparative analyses from 156 plans and insurers, and none contained adequate data upon preliminary receipt. Whereas the overview course of is ongoing and no closing determinations have been issued, the report highlights that the DOL in the end obtained adequate data to make preliminary determinations of noncompliance for 30 plans and insurers in reference to 48 impermissible NQTLs. The report outlines a protracted checklist of widespread deficiencies among the many analyses acquired up to now, together with a reliance on conclusory assertions that lack particular supporting proof or detailed clarification.
EBIA Remark: This report serves as a wake-up name to well being plan sponsors, insurers, and advisors, a major variety of which, in response to the report, had been unprepared to offer the required comparative evaluation when requested regardless of having imposed NQTLs for years. Stressing that “proactive and rigorous enforcement is important,” the report recommends that Congress amend ERISA to authorize the DOL to evaluate civil financial penalties for parity violations and instantly pursue parity violations by entities that present administrative companies to ERISA group well being plans (together with well being insurers that present administrative companies to ERISA plans and TPAs). For extra data, see EBIA’s Group Well being Plan Mandates handbook at Sections IX.A (“What Is Psychological Well being Parity and Who Should Comply?”), IX.H (“Psychological Well being Parity Reporting Necessities”), and IX.J (“Psychological Well being Parity: Enforcement”). See additionally EBIA’s Self-Insured Well being Plans handbook at Part XIII.E (“Protection Limitations and Exclusions”).
Contributing Editors: EBIA Employees.