by the Eating Disorders Coalition

EDC Succeeds in Efforts to Strengthen Parity



Earlier this morning SAMHSA and Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) convened a conference to go over the final Mental Health parity rule.  EDC participated on that call.

What’s described below are the five (5) differences between the Interim Final Rule and the final regulation released today.

1.)    Clinically Appropriate Exception: The final rule removes the “clinically appropriate exception” from the Non Quantitative Treatment Limits (NQTL) portion of the regulations.  Dr. Frank from ASPE explained that there is plenty of flexibility within existing regulations to apply clinical rationales to treatment decisions and, further, there was some evidence that the exception was abused.

2.)    Multi-Tier Plans: The final rule recognizes multi-tier plans and multiple provider networks. However…

  • Tiers can’t be structured or used to discriminate against people with chronic illnesses including behavioral health disorders.
  • The “substantially all” and “predominance” tests apply across all tiers.

3.)    Network Disclosure Requirements:  Managed Care Organizations (MCOs)/Insurance plans must disclose medical necessity definitions and the processes used to construct NQTLs

4.)    Small Groups Plans: The rule increases detail on the small group cost exemption…..and specifically states that small group plans offered in the exchanges aren’t eligible for the exemption [consistent with our understanding of the ACA Stabenow amendment]

5.)    Scope of Services/Residential Treatment: This is probably the biggest single news item. So, the final rule defines intermediate services…and creates a cross walk between medical/surgical care and behavioral health services….requiring that they be handled in a “comparable fashion” relative to cost sharing/duration limits. Further,

  • While the rule doesn’t require that residential services be covered, it says that if MCOs or health insurers offer “post-acute care services,” then they must cover residential treatment and other intermediate services on the behavioral health side. In the plain English, that seems to mean that if a health insurance plan covers chemotherapy [a post-acute oncology intervention after hospitalization], then it must cover residential treatment of substance use disorders or eating disorders.
  • In addition, in setting up their provider network, if an MCO/insurer doesn’t require a patient to go out of state to access post-acute care medical/surgical services, then it can’t force patients with mental illnesses/addiction disorders out of state to access behavioral health residential treatment services.

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