In our previous Compliance Update, WebTPA mentioned the nonquantitative treatment limitations (NQTLs) comparative analysis, under the Mental Health Parity and Addiction Equity Act (MHPAEA). Group health plans must apply any processes, strategies, evidentiary standards and other factors underlying NQTLs to mental health or substance use disorder (“MH/SUD”) benefits comparably to those for medical/surgical (M/S) benefits.
While health plans have conducted parity comparative analyses for years as a best practice, the Consolidated Appropriations Act (CAA) codifies this best practice into law. As of February 2021, plans must be prepared to make these analyses available to the Department of Labor (DOL), Health and Human Services (HHS) and Treasury Departments (collectively referred to as “the Departments”), or the appropriate state authority, within 45 days of a request.
The MHPAEA Self-Compliance Tool is available on the DOL’s website and serves as a guide in completing the full parity analysis. Section F within the tool specifically addresses NQTLs and includes several examples.
As we typically bring managed care solutions to the group health plans we serve, we are able to coordinate the completion of the comparative analyses for the following NQTLSs that may apply to our clients’ health plans:
• Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative
• Prior authorization or ongoing authorization requirements
• Concurrent review standards
• Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as “fail-first” policies or “ step therapy” protocols)
• Exclusions based on failure to complete a course of treatment
WebTPA will also contact vendors who provide out-of-network repricing and discuss the methods used for determining usual, customary, and reasonable charges.
Other NQTLs include prescription drug formulary design, multiple network tiers (such as preferred providers and participating providers), network tier design, standards for provider admission to participate in a network, and network reimbursement rates for providers. As plans separately choose vendors to provide pharmacy benefit management, network and other services, they will need to contact these entities directly for their analyses.
The design of a health plan includes additional NQTLs such as methods for determining exclusions of specific treatments for certain conditions, restrictions on applicable provider billing codes, standards for providing access to out-of-network providers, and restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits. The plan should document the details surrounding these design choices.
For all comparative analyses, general and summarized statements alone do not meet the Department’s criteria and rather, they expect detailed and supported strategies, evidentiary standards and factors, and how the standards were defined and applied. The Departments recently published FAQs Part 45, which highlights this and other important points about the NQTL comparative analysis.
Plans subject to ERISA must make its NQTL comparative analyses and other relevant information available to plan participants, beneficiaries and enrollees upon request. Further, NQTL analyses fall within the scope of a claimant’s right to reasonable access to documents and information relevant to a claim for benefits under ERISA.
If you are looking for consultation or legal assistance in working through the entirety of the MHPAEA Self Compliance tool, please let us know as we may be able to direct you to external resources who provide this service. Thank you!