If you’ve read our previous blog, you know that the final rule for MHPAEA came out on Friday. EDC has taken a look at the regulation to determine how we anticipate it will affect eating disorders policy, and what we anticipate the implications to be.
As a reminder, MHPAEA applies only to health plans provided by employers with 50 workers or more, and individual plans purchased through the Exchange. These rules do not apply to people in government health insurance programs such as Medicaid or Medicare.
Overall, the EDC, like many mental health advocacy organizations, is very pleased with this final rule. This is a historic first step in ensuring that people with eating disorders are able to receive the treatment that they need to recover. The final rule does clarify that insurers must cover mental health disorders at parity with medical disorders. There are three primary issues in the regulation we want to highlight: residential treatment, plan standards and disclosure requirements. All three of these areas contain substantial victories for people trying to get coverage for eating disorders.
1. Residential Treatment
While the rule doesn't require that residential services be covered, it does say that if insurers offer "post-acute care services," then they must cover residential treatment and other intermediate services for mental health.
For example, if a plan classifies care in skilled nursing facilities or rehabilitation hospitals as inpatient benefits, then the plan must also treat any covered care in residential treatment facilities for mental health as an inpatient benefit. This means that if your insurance plan covers, for example, residential rehabilitation after an accident, it must also cover comparable residential or inpatient treatment for eating disorders.
People with eating disorders have been consistently denied inpatient and residential care, while their insurance plans cover comparable medical services. The EDC has long argued this is in violation with MHPAEA, the regulations explicitly clarify this.
2. Medical Necessity Disclosure Requirements
The rule clarifies that people are entitled to information about the standards used by health plans to determine what kind of treatment they cover.
That is, the final regulations require plan administrators to make the plan’s medical necessity determination criteria available upon request to potential participants, beneficiaries, or contracting providers. This information is particularly valuable if people wish to file a complaint alleging that their eating disorder was not treated comparably to a medical one.
People receiving treatment for eating disorders have, unfortunately, experienced coverage denials (typically, inpatient or residential) because of medical necessity. For many consumers it has been nearly impossible to understand how the insurance company made their determination. Insurers have refused to disclose how the determination of ‘medical necessity ’was made. In a tremendous victory, these regulations clarify that the rationale behind these decisions must be disclosed.
3. Plan Standards
Another regulation in the final rules we want to highlight is plan standards. In setting up their provider network, if an insurer does not require a patient to go out of state to access post-acute care medical services, then it can not force patients with mental illnesses out of state to access behavioral health residential treatment services.
Additionally, an insurer may no longer exclude coverage for inpatient or residential, out-of-network treatment of mental health disorders when obtained outside of the state where the policy is written, when no similar exclusion exists for medical benefits exists.
In fact, the final rule added two additional examples of non-quantitative treatment limits (NQTL) to the illustrative list: network tier design and 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. The new
examples clarify that plan or coverage restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services must comply with the NQTL parity standard.