 |
|
Goverment Affairs |
| |
|
|
Summary
of "The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008"
|
Purpose. The Mental Health
Parity Act of 2008 will end health insurance benefits inequity between mental
health/substance use disorders and medical/surgical benefits for group health
plans with more than 50 employees. When the law is enacted, 113 million
people across the country will have the right to non-discriminatory mental
health coverage, including 82 million individuals enrolled in self-funded plans
(regulated under ERISA), who cannot be assisted by State parity laws.
The Parity
Requirement.
The bill amends the Mental Health Parity Act of 1996 to require that a group
health plan of 50 or more employees (or coverage offered in connection with
such a plan)-that provides both medical and surgical benefits and mental health
or substance use benefits-to ensure that financial requirements and treatment
limitations applicable to mental health/substance use disorder benefits are no
more restrictive than those requirements and limitations placed on
medical/surgical benefits.
-
Equity coverage will
apply to all financial requirements, including deductibles, copayments,
coinsurance, and out-of-pocket expenses, and to all treatment limitations,
including frequency of treatment, number of visits, days of coverage, or other
similar limits.
-
The bill builds on
the current 1996 parity law, which already requires parity coverage for annual
and lifetime dollar limits.
-
Mental health and
substance use disorder benefits are defined broadly to mean benefits with
respect to services for mental health conditions and substance use disorders,
as defined under the terms of the plan and in accordance with applicable
Federal and State law.
-
A plan may not apply
separate cost sharing requirements or treatment limitations to mental health
and substance use disorder benefits.
-
If a plan offers two
or more benefit packages, the requirements of this Act will be applied
separately to each package.
-
As under the current
Federal parity law, mental health or substance use benefit coverage is not
mandated. However, if a plan offers such coverage, it must be provided at
parity in accordance with this Act.
Out-Of-Network
Benefits.
A group health plan (or coverage) that provides out-of-network coverage for
medical/surgical benefits must also provide out-of-network coverage, at parity,
for mental health/substance use disorder benefits.
Benefits Management
and Transparency. As under the 1996 Mental Health Parity
Act, a group health plan (or coverage) may manage the benefits under the terms
and conditions of the plan. A plan will make mental health/substance use
disorder medical necessity criteria available to current or potential
participants, beneficiaries or providers upon request. A plan must also
make reasons for payment denials available to participants or beneficiaries on
request or as otherwise required.
Preservation of State
Law.
The current HIPAA preemption standard applies. This standard is extremely
protective of State law. Only a State law that "prevents the application"
of this Act will be preempted which means that stronger State parity and other
consumer protection laws remain in place.
Small Employer
Exemption. As with the current 1996 Federal parity
law, small employers of 50 or fewer employees are exempt from the requirements
of the Act. State parity laws will continue to apply to these employers,
as well as to individual plans.
Cost Exemption. If a group
health plan (or coverage) experiences an increase in actual total costs with
respect to medical/surgical and mental health/substance use benefits of 1% (2%
in the first plan year that this Act is applicable), the plan can be exempted
from the law.
-
An employer may elect
to continue parity coverage regardless of this cost increase.
-
The exemption shall
apply for one plan year.
-
A qualified actuary
(member of American Academy of Actuaries) shall determine and prepare a written
report regarding a plan's cost increase after a plan has complied with the Act
for the first six months of the plan year involved.
-
A plan shall promptly
and timely notify the Department of Labor (if self-funded) or the Department of
Health and Human Services (if fully-insured), the appropriate State agencies,
and participants and beneficiaries when it elects an exemption. Plan
notification to Labor or HHS is confidential and will provide a description of
covered lives in the plan and the actual costs for which the exemption is
sought.
-
Labor or HHS (as
appropriate) and State agencies may audit a plan to determine compliance with
the Act when the plan has elected an exemption.
Compliance Report. By 2012 and
every two years after, the Labor Secretary shall submit to Congress a report on
group health plan (or coverage) compliance with this Act. The report will
include the results of any compliance audits or surveys, and if necessary, an
analysis of reasons for any failures to comply with the law.
GAO Study. GAO will
conduct a study that analyzes the specific rates, patterns and trends in
coverage, any exclusion of specific mental health and substance use diagnoses
by health plans, and the impact of this Act on such coverage and costs.
GAO will provide a report to Congress within three years (and an additional
report after five years) on the results of the study.
Consumer Assistance. The Labor
Secretary, in cooperation with the HHS and Treasury Secretaries, shall publish
and disseminate guidance and information for plans, participants and
beneficiaries, applicable State agencies, and the National Association of
Insurance Commissioners concerning the requirements of this Act. This
information will include assistance with questions and how participants and
beneficiaries can obtain assistance from State consumer and insurance agencies.
Enforcement. As under the
1996 law, Labor, HHS, and Treasury will continue to coordinate enforcement of
the Federal mental health parity requirements and are required to issue
regulations to carry out changes made in this Act not later then one year after
the enactment date. Treasury may continue to impose an excise tax on any
plan for failure to comply with the requirements of the Act.
Effective Date. The Act will
apply to plans beginning in the first plan coverage year that is one year after
the date of enactment. For most plans, this will mean the effective date
begins on January 1, 2010. Plans maintained under collective bargaining
agreements ratified before the enactment date are not subject to the Act until
they terminate (or until January 1, 2009, if this is a later date). The
current 1996 parity act requirements for annual and lifetime dollar limits
remain in effect for all plans, while the annual sunset in the 1996 parity act
is eliminated, effective January 1, 2009. |
|
| |
|
|
|
|
|
 |
