Plan year as of October 3, 2009 or after must meet the Equal Employment addiction 2008 (MHPAEA) parity of mental health and requires group health plans and health insurance issuers to use mental and addiction services to ensure the same level as the medical or surgical benefits. This applies to the health plans of private and public groups with more than 50 employees. MHPAEA plans must meet auto insurance. 'S MHPAEA not require a group health plan is to related disorders mental health or addiction. Only the equal treatment of abuse benefits medical / surgical and mental health / substance use disorders is required if both offered under the plan.
Group health plans that are under MHPAEA, subject to three main requirements.
- Limitations and / or year of life
- This means that health plans group that annual limits apply and / or U.S. dollars of life for medical / surgical services must have the same or less restrictive dollar limits for mental health benefits and benefits addictions are benefits in the same classification.
- Parity in the financial position and the maximum treatment
- Financial requirements (such as deductibles, copayments, coinsurance and maximum out of pocket) and the quantitative treatment limitations (such as the number of treatments, visits or days of coverage) must be equal to or less restrictive mental disorder or be using substances for medical / surgical benefits in the same category of benefits.
- The parity for the treatment of non-quantitative restrictions
- Things such as medical management standards must be treated equally or less restrictive use of mental health services or substance for medical / surgical benefits in the same classification benefits.
Measuring benefits
The standards establish applied to classification by classifying six categories of benefits and requirements parity.
- Red steady
- Hospital patients, from network
- Ambulatory Network
- Outpatient, non-network
- Emergency care
- Prescription drugs
If a benefit is a medical / surgical services, or use of health / substance advantages of mental disorder is generally described by the standards of medical practice than the current version of the Diagnostic Statistical Manual of Mental Disorders (DSM) accepts determines the current version of the International Classification of Diseases (ICD) or State guidelines. These advantages are also advantages for products and services. Medical conditions, surgeries, mental disorders and addictions are defined according to the provisions of the plan or coverage and in accordance with applicable federal and state law.
Mental health / substance abuse treatment limitations should use health disorder "not more restrictive than the predominant treatment limitations that are substantially all created" by the health care plan / surgical be covered. He has this sentence three tests:
- is the statute of limitations applies to almost all medical / surgical benefits;
- is the predominant treatment limiting; and
- is more restrictive in the use of the benefits of health / substance of the mental disorder that the medical / surgical benefits?
- "Almost all" means a treatment limitation applies to at least ⅔ of the advantages of classification. If a treatment limitation does not apply to this limit, the limitation of the treatment, the benefits are not used by mental disorders in this category for the health / substance use.
- "Dominant", limiting the treatment is applied at least half of the profits in a classification. If a treatment limitation does not apply to this limit, the limitation of the treatment, the benefits are not used by mental disorders in this category for the health / substance use.
Entry into force
The final regulations were published in November 2013. Group health plans for plan years beginning on July 1, 2014 (January 1, 2015 for calendar year plans). Until then, the plans must continue to comply with the last transitional provisions that have been in place for several years.
Exceptions
MHPAEA does not apply to small employers with fewer than 51 employees or individual plans and small groups, protecting the status quo should be applied. However, other countries may have laws on the subject and small businesses should be aware of the need for primary care (see below) to be.
Missouri Regulations
In addition to the national leadership, Missouri additional rules issued on the mental health parity.
- Depending on the state of mental health, residential treatment may or may not be covered.
- Treatment of Chemical Dependency living through health plans and groups drawn separately covered.
- All other mental health conditions, which are classified in the Diagnostic and Statistical Manual of Mental Disorders IV, would be covered.
- If a plan decides to close antidepressants in their prescription drug coverage, you can no financial burden on an insured for access to treatment for a physical health problem.
- Supports group health plans must provide protection for medically necessary treatment of learning disabilities, developmental delays and mental retardation and autism.
- Insurance companies are able to determine what is "medically necessary." MHPAEA requires insurance for their medical necessity criteria available to current plans and potential participants. In case of rejection the health of plan participants do not have to, because decisions about the medical necessity or for other reasons to learn why he rejected a request, too.
- self-funded plans that fall under ERISA or the Act, subject to regulation by the Missouri but are not subject to MHPAEA.
Illinois Regulation
Illinois law requires employers of 51 or more employees offer the use of mental health services and addiction groups.
- Illinois law requires insurance companies and HMOs offer, the group hospital or medical benefits coverage to cover mental health treatment companies, other than "serious mental illness" to the insured regardless of the size group. If the insured accepts, the policy must provide benefits for serious mental illness.
- Severe mental illness is defined according to the criteria of the DSM as Illinois:
- Schizophrenia;
- Paranoid and other psychotic disorders;
- Bipolar disorders (hypomanic, manic, depressive and mixed);
- Depressive disorders (single episode or recurrent);
- Schizoaffective disorder (bipolar or depressive);
- Pervasive developmental disorders;
- Obsessive-compulsive disorder;
- Depression in childhood and adolescence;
- Panic disorder;
- Posttraumatic stress disorder (acute, chronic or delayed); and
- Anorexia nervosa and bulimia
- Severe mental illness is defined according to the criteria of the DSM as Illinois:
- Individual insurance policies are not required by law of Illinois, provide coverage for treatment of mental illness, but HMO individual measures are required to provide the following benefits, depending on state law.
- 10 days mental health care for hospital patients per year. Care in a day hospital, ambulatory or outpatient residential intensive method, by two to one be substituted for hospital services than by the GP appropriate.
- 20 single rooms for outpatient mental health services for enrolled visits per year, depending on the assessment, treatment services and short-term crisis intervention. Visitors from outside groups of mental health services by one to two visits to the psychiatric care of persons deemed to be replaced by the GP as appropriate.
Coverage for serious mental illness in Illinois requires parity with financial, such as the dollar limits, deductibles and coinsurance requirements requirements. Notwithstanding the determination of medical necessity, in each calendar year, the coverage of these services can not be smaller;
- 45 days after the treatment in the hospital,
- 60 outpatient visits and
- An additional 20 visits for speech therapy for the treatment of pervasive developmental disorders on an outpatient basis.
Affordable Care Act interactions
- As of 2014, such a small group and individual market plans to meet March 23, 2010 created with the requirements of the federal parity.
- Qualified health plans offered by health insurance markets in every state should include health and substance psychological abuse as one of the ten categories of the essential health benefits and coverage, the requirements must meet established federal parity in MHPAEA.
The essential health services
The Affordable Care Act also an impact on the right to mental health parity through some of its laws. MHPAEA not apply directly to health plans in small groups, but its requirements apply indirectly through the essential health benefits (EHB). Insurance coverage can not be excluded in the individual and small group market through an exchange or outside the exchange, the requirements of Rule MHPAEA must meet in order to satisfy the requirement of the EHB. These requirements are that a plan must provide EHBs limit the distribution of costs and offer either a bronze, silver, gold or cover on the board or on a catastrophic level. The ten categories of EHB are:
- Outpatients
- Emergency services
- Hospitalization
- Maternity and newborn care
- Use of mental health services and addiction disorders, including mental health treatment
- Prescription drugs
- Equipment for the rehabilitation and adaptation or rehabilitation
- Laboratory services
- Preventive and wellness services and chronic disease management
- Children's services, including oral and vision care
Possible Challenge
"Exclusion" health benefits are the mental health benefits that are acquired separately by employers medical services. This presents a challenge for the application of MHPAEA because it can be separated from the health benefit of the seller. If this is the case, requires the seller to "carve-out" around parity with the medical services that provide by another provider of the law.
Sanctions
ERISA contains no penalty or regulations to implement specific violations of the Port Authority or MHPAEA. However, the participants, beneficiaries and the Ministry of Labour civil enforcement provisions of ERISA can continue to use to meet the requirements of the Port Authority and reason MHPAEA.
This process may involve fulfill violation of the duty of care for non-compliance with the MHPA or MHPAEA, required to pay or psychological benefits presumed to be due and damages for unpaid benefits, interest and attorney fees.
The IRS can impose excise taxes for the failure of a group health plan to meet failure $ 100 per day for each person that is related.
For more information:
https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-27086.pdf
http://www.nami.org/Content/ContentGroups/Policy/Issues_Spotlights/Parity1/FAQ_MHPAEA_7_10.pdf
