NQTLs are processes, strategies, evidentiary standards, or other criteria that limit the scope or duration of benefits for services provided under the plan. Certain utilization reviews, prior authorization and plan provisions may only be applied to mental health/substance use disorder benefits if they are comparable to or less restrictive than those for medical surgical services.
NQTLs include, but are not limited to:
- Medical management standards limiting or excluding benefits based on medical necessity, medical appropriateness, or based on whether the treatment is experimental or investigative (including standards for concurrent review).
- Formulary design for prescription drugs.
- Network tier design.
- Fail-first policies or step therapy protocols. For example: Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective.
- Exclusions based on failure to complete a course of treatment.
- Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage.
QTLs can be measured numerically. Health insurers generally cannot impose a financial requirement (such as copays, coinsurance, deductible) or a QTL (such as the number of outpatient visits or inpatient days covered) on mental health/substance use disorder benefits that are more restrictive than the financial requirement or QTL that apply to most – but not all – medical surgical benefits in the same classification.
MHPAEA protections extend to most health plans, including self-insured and fully insured:
- Individual health plans issued on and off the Health Insurance Marketplace
- Large group health plans, including private and public-sector employers with more than 50 employees (certain self-insured governmental plans may opt-out).
The Patient Protection and Affordable Care Act (ACA) requires small group plans to provide mental health/substance use disorder benefits. Any plan that offers mental health/substance use disorder coverage must comply with MHPAEA.
If your insurance includes prescription drug coverage, it will include benefits for all drugs that your insurer has included on its formulary. If the drug your doctor prescribed is not covered on your insurance formulary, you may be required to appeal to your insurer to use the uncovered drug, or try an alternative drug first.
If your insurance limits non-emergency care to in-network doctors and facilities, then your insurer can require you to go to an in-network facility in order to receive services. There may be some exceptions if you are experiencing an emergency or you have a need that can’t be met by an in-network doctor or facility.
Particular benefits must be covered under the terms of your insurance policy in order for your insurer to pay for them. Insurers can also require that the service meet criteria to be considered medically necessary before they issue prior authorization for the service.
Yes. A complex formula is used to determine the maximum cost-share that an insurer may charge for mental health or substance used disorder services The copay or coinsurance for some medical services may still be lower than the maximum mental health services cost-share.
Unless it’s an emergency or the patient could be harmed, insurers may require patients to try less involved or intensive treatment first.
Some group health insurance policies are not required to provide mental health services at parity with medical services.
Individual health insurance policies issued prior to 2014, and some group health insurance, do not have to cover mental health/substance use services. In addition, short term and limited benefit policies do not have to include mental health benefits.
Parity means parity within your own plan and not parity between plans.
MHPAEA requires that insurers meet mental health parity standards in two areas: quantitative limits and non-quantitative limits.
- Plans must apply comparable financial requirements (such as copay, coinsurance, & deductible) for mental health/substance use disorder and medical surgical care.
- The number of outpatient visits or inpatient days covered must be comparable for mental health/substance use disorder and medical surgical care.
- Prior authorization requirements for mental health/substance use disorder services must be comparable to or less restrictive than those for medical surgical services.
These standards are applied according to classifications of benefits:
- Inpatient / in-network
- Inpatient / out-of-network
- Outpatient / in-network
- Outpatient / out-of-network
- Emergency care
- Prescription drugs
Parity means that financial cost-sharing requirements for mental health/substance use disorder benefits (such as deductibles, copayments, coinsurance, and out-of-pocket limitations) must be comparable but not identical to those for medical surgical. Parity also applies to rules regarding care management (authorization for treatment) and treatment limitations.
Although benefits may differ across plans, parity requires that the processes related to plan benefit determinations be comparable. The ACA contributed to parity by eliminating annual and lifetime dollar limits for mental health/substance use disorder benefits.
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law requiring health plans to apply similar financial and treatment limits to mental health/substance use disorder benefits and medical surgical benefits.