News Flash: There is no real statutory mandate that employers offer group health coverage, let alone coverage for specific conditions. However, federal law requires health plans that provide coverage for mental health and substance use disorders to ensure that financial requirements (such as coinsurance) and treatment limitations (such as visitation limits). and provider access) applicable to these benefits are not more restrictive than the predominantly applicable requirements. medical and surgical services. By default, employers who sponsor group health insurance plans are generally responsible for meeting these and other federal requirements.
It was fairly easy for employers to assess whether financial the financial requirements are on par or to obtain assurance from an insurer, third-party administrator or actuary that the financial requirements are on par. Corn processing limits is another matter because, in addition to visitation limits (which must be disclosed in the certificates of coverage and summary descriptions of plans provided by insurers and plan service providers), processing limitations include certain non-quantitative limitations. that are not usually disclosed to employers or plan members. Rather, they are limits or restrictions which cannot be expressed numerically and which result from the design characteristics of the scheme and the network development procedures which, historically, were the exclusive domain of insurers and third-party administrators. Most employers do not have the resources to design a group health plan and create a provider network on their own, so they simply buy a pre-packaged plan plan and access an âoff the shelfâ provider network. . Nonetheless, employers remain responsible for compliance, especially employers with self-insured group health insurance plans.
As the demand for mental health and substance use disorder benefits has increased, many employers and plan members are finding that their group health plan coverage for these benefits is sorely lacking … and confusing. The problems arise from the fact that mental health and substance use disorder services are more likely to be provided outside the network, as reported by Milliman and others. There are several reasons for this, but the Employee Benefit Security Administration of the United States Department of Labor (the agency responsible for enforcing the Mental Health Parity and Addiction Equity Act) seems particularly interested in identifying claims handling procedures, provider accreditation and reimbursement rates which tend to limit the benefits for mental health and substance use disorders more than the medical and surgical benefits.
Over the past two years, the DOL has secured multi-million dollar settlements from insurers that have allegedly placed tighter restrictions on mental health and substance abuse claims, based on analysis of data from DOL complaints. Increasingly, however, the DOL is probing deeper, beyond claims data and more into how plan networks are developed – provider admissions procedures and reimbursement rates that are not transparent. for employers or plan members. We’ve seen DOL focus its group health plan investigations around these non-quantitative treatment limitations.
The Consolidated Appropriations Act enacted in December 2020 amended the Federal Parity Mental Health Act to require plans to conduct and document benchmarking of non-quantitative treatment limitations by February 10, 2021. The DOL wasted no time launching inquiries after that to see if the plans were in line. The new law requires the DOL to do so in time to report to Congress in late 2021 and publish a list of non-compliant plans. In addition to providing benchmarking documentation to DOL upon request, plan sponsors must also provide benchmarking documentation to plan members. Again, all group health insurance plan sponsors – whether the plan is fully insured or self-insured – are responsible for ensuring that the benchmarking is completed and provided upon request. However, in the case of the fully insured plan, the insurer is also liable under the law. Therefore, sponsors of fully insured plans can at least expect that the benchmarking has already been performed by the insurer.
The comparative analysis documentation should identify the non-quantitative treatment limitations and the benefits to which they apply as well as the factors and standards or evidentiary strategies considered in the design or application of the limitations. It should also explain whether there is a variation in the application of a guideline or standard between the mental health benefits / substance use disorders and the medical / surgical benefits and, the if so, why. In its investigations, the DOL requests and analyzes applications for admission to the supplier network and the reasons for refusal of admission, accreditation requirements and the reasons for these requirements, supplier contracts, supplier fee schedules. and the methodology of their development, and the geographic and other standards considered to establish the network provider. This is not information that employers have historically had access to, but it is now information that employers must obtain.
Now is the time for an employer to oppose enforcement action, before the plan and its sponsor are exposed. For a self-insured group health plan sponsor, this means obtaining assurance from plan service providers that the plan complies with Federal Parity Mental Health Act and that documenting benchmarking analyzes of limitations. non-quantitative treatment is readily available. Unfortunately, some plan sponsors find out – too late – that their plan service providers have not performed or documented the benchmarking and are not accepting responsibility for it either.
Jackson Lewis PC Â© 2021Revue nationale de droit, volume XI, number 326