A new federal law will require employer-sponsored health plans to take a closer look at how they offer mental health benefits compared to medical and surgical treatment to ensure they meet the enhanced requirements.
The rule (RIN: 1210-AC11) was completed on Sept. 9 by the departments of Health and Human Services, Labor and Treasury aims to increase access to mental health care by requiring health plans to make detailed comparisons between the health of psychology and medical protection.
Introduces several new parity tests under the Mental Health Parity and Addiction Equity Act of 2008 for “unlimited treatment gaps,” such as “prior authorizations” that require patients to obtain consent from their insurance company before they receive the drug or service.
The industry’s response raises questions about how the law would hold up against a legal challenge after the US Supreme Court’s decision Loper Bright Enterprises v. Raymondwhich was overturned Chevron the doctrine of pushing for a rational interpretation of abstract legal entities. Administration officials have pledged to work on compliance plans, but one group of employers is considering a lawsuit.
The industry’s confusion stems from a “year-old” problem of a lack of guidance on mental health, said Rebecca Hanson, a partner at Reed Smith LLP. Although this law made it more clear by continuing to define what the departments are looking for in comparison, the organizations have not yet provided specific examples of how to comply with the new law.
“The big question remains how to follow through,” he said.
Employer groups have said that the administrative burden of writing NQTLs could force employers to drop mental health coverage altogether. The law prohibits plans from placing restrictions on mental health services unless it is a primary restriction that applies to the “substantial” medical benefits of the plan in the same categories.
Although the final rule eliminated the proposed model’s requirement to use statistical tests to evaluate whether the restriction has been applied to the “general” purpose, employer plans must still demonstrate that they are collecting and check the relevant information to show the effect of NQTL and show. equality. They will also be required to comply with additional planning and application requirements to maintain their use of the NQTL.
While the law’s implementation is delayed until 2026, plans should begin collecting data from third-party vendors now, Hanson said, because they only have 10 business days to respond to the request. of comparative analysis from departments.
“Make sure you have good information, that you’ve talked to all your stakeholders, and make everyone aware that we need these types of data,” he said.
Many clients already have strong balancing programs, which makes it easier, said Kevin Malone, who advises mental health programs as a member of the Epstein Becker & Green PC But uncertainty remains.
“There’s no way to be 100% sure that you’re listening because you’re rejecting the idea of discrimination,” he said, adding, “But we know where to start.”
Revisiting the Status Quo
The overall message of the plans is not to rely on the status quo, said Legal Action Center Senior Health Policy Advocate Deborah Steinberg, who works to expand federal and state equity regulations.
He cited a case involving one plan that had not updated its out-of-network premiums since 1983. they don’t discriminate, Steinberg said. , because they came well before the 2008 law.
“Those charges are not based on the same information. At that time they did not have to comply with the gender equality law,” he said. You can’t keep doing the things you’ve always done.
The industry is waiting for further guidance for now, Malone said. Clients are looking for metrics that departments will use to assess whether the design meets the legal bases in the NQTLs for everything from the donor acceptance process to audits and investigations. to exclusion and rejection of applications.
He said: “These are all subject to equality and they are all very different. “So the data you have to use to evaluate the different impact of those activities, if they are discriminatory or not – to find out What is data is the challenge.”
He pointed to adequate network standards—which help determine whether enrollees have adequate access to mental health and traditional medicine providers—as an example of requirements that could have an impact. great in the broad framework of the plan. The organizations asked for comments on the proposed rule that they plan to use in future guidelines.
“This could be a very big deal if the three organizations go ahead and finalize the new network parity standards,” he said. “That’s for the sake of balance, but it still works for the benefit of all.”
Strengthening the provider network is one of the most important areas of law for consumer advocates as well. Finding an online provider is one of the most common problems patients face, Steinberg said. The country’s lack of mental health alone is not always responsible for the lack of online voting policy, he said.
He pointed to an April 2024 study cited by RTI International, which found patients go online for mental health care 3.5 times more than medical and surgical care.
“There is no doubt that there are many areas in the country where there is a shortage of mental health providers, but if people are able to access their care offline, it means that there are providers who there, so projects need to do more to get those providers in their network,” he said.
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