Mental health parity regs cover treatment limits and gatekeepers
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Mental health parity regs cover treatment limits and gatekeepers

New regulations require mental health parity in insurance coverage

Government regs defining compliance with the new Mental Health Parity Act have finally come out, and there are a couple of important new points you need to know about.

Some things were already clear just from the Mental Health Parity law. Any employer of 50+ people that offers a plan with mental health/substance abuse benefits must:

  • provide them at the same level as medical/surgical benefits, and
  • drop any previous plan limits on mental health coverage.

Quantitative rules
The rules apply quantitative parity – how much treatment is allowed, what deductible is due – across six mental health benefit categories:

  1. inpatient in-network
  2. inpatient out-of-network
  3. outpatient in-network
  4. outpatient out-of-network
  5. emergency care
  6. prescription drugs.

In any of these classes, a health plan can’t apply a financial requirement or treatment limit to mental health/substance abuse benefits that’s tighter than the most common limit for “substantially all” medical/surgical benefits in that class. (“Substantially all” means at least two-thirds.)

Non-quantitative rules
The regs also require parity in non-quantitative treatment limits. These include medical management, standards to admit a provider to a network, and formulary design.

Example: An employee assistance program (EAP) can’t be a gatekeeper, restricting or directing mental health care, unless similar management is also used for medical/surgical benefits.

Also, employers can’t require employees to exhaust EAP benefits before they can access mental health care if a similar requirement does not exist for accessing other medical care.

You can find more at:

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