Figure 1: Evolution of Federal Mental Health Parity
Appendix Table 1: Major Differences – Commercial MHPAEA v. Medicaid MHPAEA
Definition of behavioral health
Plans define what is considered behavioral health versus medical care.
State Medicaid agencies can define what is behavioral health versus medical care. MCOs, PHIPs and PAHPs must follow the state’s definition.
Long term care services
Long term care services are considered “excepted benefits” that do not have to comply with parity.
Long term care services generally must meet parity standards.
Plans must evaluate parity for out-of-network inpatient care and out-of-network outpatient care.
The two out-of-network classifications do not apply to Medicaid MHPAEA.
Plans can determine parity separately for each provider network tier in a classification.
Medicaid parity regulations do not give Medicaid plans with network tiers the ability to evaluate parity within each tier. Parity is evaluated for all care within a classification.
Cumulative Quantitative Treatment Limits
Quantitative treatment limits (such as a limit on the number of visits for a service per year) cannot accumulate separately for behavioral health and medical.
Quantitative treatment limits can accumulate separately for behavioral and medical services if certain standards are met.
Disclosure of reasons for denial of a claim
Plans subject to ERISA must provide the denial reason in the form/manner included in ERISA claims review rules that are separate from commercial parity rules. NonERISA plans that follow this form and manner are deemed to comply with this parity requirement.
Medicaid is subject to its own form/manner notice standards for providing the reason for a claim denial in adverse action notice regulations that are separate from Medicaid parity rules.
Plans can qualify for a temporary exemption from meeting the MHPAEA standards if they meet certain requirements for cost increases.
Medicaid regulations do not apply the cost exemption to Medicaid.
SOURCE: 70 Federal Register 68240-68296; 80 Federal Register 18390-18445