Health plans and insurers that impose a nonquantitative treatment limitation (NQTL) on mental health or substance use disorder benefits (such as a restriction based on facility type) must perform and document a comparative analysis of the NQTL’s design and application. Other NQTL limit examples include quantitative (i.e., visit limits) and nonquantitative treatment limitations (i.e., preauthorization and pre-service notification obligations).
Beginning 45 days after the Consolidated Appropriations Act of 2021’s (“CAA”) enactment (February 10, 2021), the comparative analysis and other specific information must be made available to the applicable state or federal agency (i.e., Secretary of Labor or the Secretary of Health and Human Services) upon request. The specific information that must be reported includes:
- The specific plan or coverage terms or other relevant terms regarding the NQTLs and a description of all mental health or substance use disorder and medical or surgical benefits to which each such term applies in each respective benefits
- The factors used to determine that the NQTLs will apply to mental health or substance use disorder benefits and medical or surgical benefits.
- The evidentiary standards used for the factors identified above, when applicable, provided that every factor shall be defined, and any other source or evidence relied upon to design and apply the NQTLs to mental health or substance use disorder benefits and medical or surgical benefits.
- The comparative analyses demonstrating that the processes, strategies, evidentiary standards, and other factors used to apply the NQTLs to mental health or substance use disorder benefits, as written and in operation, are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, and other factors used to apply the NQTLs to medical or surgical benefits in the benefits classification.
- The specific findings and conclusions reached by the group health plan or health insurance issuer with respect to the health insurance coverage, including any results of the analyses that indicate that the plan or coverage is or is not in compliance with this section.
The CAA requires regulators to request, at a minimum, 20 plans/issuers to submit their comparative analysis for review each year. In addition, regulators will request these reports when there is a potential violation regarding noncompliance with the reports or a complaint alleging noncompliance. If, after reviewing the comparative analysis, a federal agency determines that the NQTL does not comply with applicable parity requirements, the plan or insurer must specify the corrective actions it will take. If, following those actions, the agency determines that the plan or insurer remains out of compliance, then the agency must notify enrolled individuals of the noncompliance.
See the website for the Department of Labor to find their MHPAEA tool for additional information and contact Contribution Health at Compliance@ContributionHealth.com for more information on whether your company may be subject to the reporting requirements.
Please be aware that the determination of the requirements and the application of specific laws and regulations to each employee welfare plan and/or employer may differ due to a number of variables. Nothing in this newsletter should be construed as tax or legal advice.