The Department of Labor has provided sample mental health/substance abuse (MH/SA) plan provisions that require scrutiny to determine compliance with the federal Mental Health Parity rules (MHPAEA). Here are some common red flags:
Pre-Authorization or Pre-Service Notification requirements
– Blanket requirements for all MH/SA services
– Review required following a certain number of days of in-patient treatment
– Medical necessity and prescription drug reviews that differ from those imposed on medical services (such as deferring to attending physicians for medical reviews but not MH/SA or requiring authorization every 90 days for prescriptions relating to MH benefits but not medical)
– Pre-notification requirements for extended out-patient visits
Fail-First Protocols
– Lack of progress with less intensive treatment required prior to intensive out-patient treatment
– In-patient SA rehabilitation is not authorized unless patient first fails with out-patient treatment
– In-patient MH treatment is not authorized unless patient first completes a partial hospitalization treatment option
Probability of Improvement
– Residential treatment is covered only if there is a likelihood it will result in measurable improvement
Written Treatment Plan Required
– Plan requires a written treatment plan for MH/SA benefits
Other
– Benefits excluded if patient fails to comply with treatment plan requirements
– Exclusion of residential level of treatment
– Geographical limitations that differ from those imposed on medical benefits
– Licensure requirements imposed for MH/SA facilities but not for medical facilities
Plans with these types of provisions should carefully compare them to the rules imposed for medical/surgical benefits to ensure compliance with the MHPAEA. For more information, please click here to view the fact sheet released by the Department of Labor.
