The Internal Revenue Service, U.S. Department of Labor, and U.S. Department of Health and Human Services have jointly released final regulations and new FAQs implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA provisions generally became effective for plan years beginning on or after October 3, 2009, with interim regulations becoming effective for plan years beginning on or after July 1, 2010. The final rules become effective for plan years beginning on or after July 1, 2014, and apply to both grandfathered and non-grandfathered plans.

The final regulations largely mirror the interim regulations but add new examples and further clarifications. They also clarify the Patient Protection and Affordable Care Act of 2010 (ACA) expansion of MHPAEA coverage to include individual and small group health plans, whether or not offered on a health care exchange. The final regulations also indicate that compliance with the MHPAEA is required to satisfy the Essential Health Benefits (EHB) requirements of the ACA.

The final regulations confirm that the MHPAEA does not require group health plans to provide mental health or substance use disorder benefits, although certain preventive health screenings under ACA’s preventive health benefit need to be included. Plans that provide mental health and substance abuse disorder benefits, however, may not impose financial requirements or treatment limitations (quantitative or nonquantitative) that are more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits.

Like the interim regulations, the final regulations define “mental disorder” by reference to the Diagnostic and Statistical Manual of Mental Disorders (DSM), state guidelines, or other general accepted independent standards. The final regulations do not offer definitions of specific disorders, such as autism.

The final regulations provide further clarification and guidance on the MHPAEA requirements, including: 

• Confirming that the parity standards apply to intermediate levels of mental health or substance abuse disorder care received in residential treatment and intensive outpatient settings
• Retaining the six benefits classifications (in-patient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, emergency care, and prescription drugs), and requiring a classification by classification basis, but removing an exception in the interim regulations that allowed variation in benefit levels where “clinically appropriate standards of care” permit a difference
• Requiring a disclosure to plan participants upon request for denials of treatment on the basis of medically necessary determinations, indicating the reasons for denial of reimbursement for any mental health or substance abuse in certain circumstances
• Providing that parity applies to all plan standards, including geographic limits, facility-type limits, and network adequacy
• Clarifying that state law mandates that do not prevent the application of the MHPAEA are not preempted by the MHPAEA and acknowledging that a state law mandating coverage of at least minimum medical or surgical benefits may require plans to provide benefits beyond the minimum for mental health benefits to comply with MHPAEA
• Confirming that MHPAEA requirements do not apply to an Employee Assistance Plan (EAP) (unless significant medical care or treatment benefits are provided) or retiree-only plans

As the federal health care reform effort gained steam, Ballard Spahr attorneys established the Health Care Reform Initiative to monitor and analyze legislative developments. With federal health care reform now a reality, our attorneys are assisting health care entities and employers in understanding the relevant changes and planning for the future. They also have launched the Health Care Reform Dashboard, an online resource center for news and analysis on developments under the Affordable Care Act.

If you have questions about the regulations or their implications, contact Robert S. Kaplan at 215.864.8417 or kaplanrs@ballardspahr.com, Jean C. Hemphill at 215.864.8539 or hemphill@ballardspahr.com, or Edward I. Leeds at 215.864.8419 or leeds@ballardspahr.com.