Information Regarding ERISA Compliance and Health Plan Audits

The Federal Government Continues its Efforts to Improve Mental Health Care

Continuing into 2024, the federal government is focusing efforts on improving access to mental health and substance use disorder (MH/SUD) care. A high priority is enforcing compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) for employer-sponsored health plans. MHPAEA is a federal law that prevents group health plans and health insurance issuers that provide MH/SUD benefits from adding additional restrictions compared to medical or surgical benefits.

 

The U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) enforces MHPAEA. According to a report, nearly 25% of its enforcement program work to focus on MHPAEA nonquantitative treatment limitations (NQTLs). If violations are found by an ESBA investigator, the health plan must remove any noncompliant plan provisions and pay denied benefits. MHPAEA contains the following parity requirements:

  • The financial requirements (such as deductibles, copayments, coinsurance and out of pocket limits) applicable to MH/SUD benefits cannot be more restrictive than the financial requirements applied to substantially all medical and surgical benefits; and
  • MH/SUD benefits may not require separate cost-sharing requirements or treatment limitations;
  • Treatment limitations (such as frequency of treatment, number of visits, days of coverage or other similar limits on the scope or duration of coverage) must also comply with the MHPAEA’s parity requirements;
  • Parity requirements on the NQLTs (medical management standards, formulary designs for prescription drugs, plan methods for determining usual, customary, and reasonable charges, exclusion based on failure to complete a course of treatment, and restrictions based on facility type or provider specialty) that plans may place on MH/SUD benefits.
    • NQLTs implements nonnumerical limits on the duration of benefits, such as prior authorization requirements, step therapy and provider reimbursement rates.

 

With EBSA’s focus on MHPAEA, employers should consider taking the following steps:

  • Consult with their dedicated Creative Benefits, Inc. team member to confirm that a comparative analysis has been completed for their health plan’s NSQLs and that it has updated terms and coverage for 2024;
  • Consider MHPAEA’s parity requirements before adjusting plan coverages of medical and surgical benefits or MH/SUD benefits.

 

EBSA conducts MHPAEA compliance reviews, including NQTL requirement reviews in all its related investigations. Creative Benefits, Inc. will release updates as more information is made available.