The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires that group health plans and group health insurers apply the same treatment and financial limits to mental health and substance use disorder benefits as they do to medical and surgical benefits. These FAQs are intended to provide an overview of the Mental Health Parity Act specifically as it applies to health insurance plans.

1. What is the basic structure of the new law?

The Mental Health Parity Act amends the existing federal mental health parity requirements found in the Employee Retirement Income Security Act (ERISA), Public Health Service Act (PHSA) and Internal Revenue Code (IRC).

2. What types of health coverage are subject to the Mental Health Parity Act?

The Act applies to ERISA group health plans and to health insurers that provide coverage to group health plans. Medicaid health plans and the State Children’s Health Insurance Program (SCHIP) are also subject to the Mental Health Parity Act. Within UniCare, this includes all of our group health plans (insured and self-funded; branded and unbranded; and National Accounts), FEP, State-Sponsored and Medicare Advantage (if offered through a large group ERISA health plan). Insurers that provide “excepted benefits” to group health plans (such as disability income insurance and long-term care and Medicare supplemental insurance coverage that is offered separately) are not subject to the new law.

3. Are all employers subject to the new law?

Only those employers with 51 or more employees are subject to this law. Employers with 50 or fewer employees, including companies in states that apply group insurance laws to “groups of one,” are exempted from the law.

4. Does the Mental Health Parity Act require plans to cover mental health or substance use disorder benefits?

No. The Mental Health Parity Act does not mandate coverage of mental health or substance use disorder benefits. Health insurance carriers may, however, be subject to state laws that mandate coverage for some or all of these benefits.

5. What takes priority, state or federal parity legislation?

Stronger state mental health parity laws are not preempted by the federal law. If, for example, a state law requires parity for all diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), this state requirement remains in place, as do state laws that require parity for specific diagnoses (usually, a list of severe mental illnesses). In addition, the act does not override an obligation created in state law to either cover or offer mental health benefits. If a state parity law does not include substance use disorder, but a plan covers substance use disorder, the coverage must be at the federal parity level.

6. What diagnoses are included?

The act imposes no requirements as to what mental health and substance use disorder conditions must be covered and did not select the DSM as the source for included codes. (Subject to state mandates when applicable as noted above.)

7. How does the Mental Health Parity Act govern the provision of mental health or substance use disorder benefits?

Health insurance plans that provide coverage for mental health or substance use disorder benefits must do the following:

Annual and Lifetime Limits
In general, the existing parity requirements applicable to annual and lifetime financial and treatment limits were unchanged. As a result, if the health insurance plan includes an aggregate annual or lifetime financial or treatment limit on substantially all medical and surgical benefits, it must either:

• apply the same applicable limits to mental health and substance use disorder benefits or
• not include an aggregate annual or lifetime financial or treatment limit for mental health or
  substance use disorder benefits that is less than the limits applied to medical and surgical benefits

Financial Requirements
“Financial requirements” are defined in the Mental Health Parity Act as including deductibles, copayments, coinsurance and out-of-pocket expenses. The financial requirements applied to mental health or substance use disorder benefits must not be more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits. In addition, the health insurance plan may not apply a separate financial requirement to mental health or substance use disorder benefits that is not applicable to medical and surgical benefits.

Treatment Limitations
“Treatment limitations” are defined as including limits on the frequency of treatment, number of visits or days of coverage or other similar limits on the scope or duration of treatment. The treatment limitations applied to mental health or substance use disorder benefits must not be more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits. In addition, the health insurance plan may not apply a separate treatment limit to mental health or substance use disorder benefits that is not applicable to medical and surgical benefits.

How does the new law affect out-of-network coverage?

Health insurance plans that cover mental health or substance use disorder benefits must provide out of- network coverage for such benefits if the plan provides out-of-network coverage for medical and surgical benefits. The parity requirements apply to the out-of-network coverage for medical and surgical benefits as well as mental health and substance use disorder benefits.

9. Can utilization reviews be applied?

Health insurance plans are not restricted from applying utilization review, medical necessity determinations or other tools to encourage appropriate and effective care. However, the act requires disclosure of the criteria for medical necessity determinations (and reasons for denials of coverage) regarding mental health or substance use disorder benefits to any current or potential participant, beneficiary or contracting provider upon request.

10. When do the provisions of the Mental Health Parity Act go into effect?

The requirements of the new law are effective for plan years beginning on or after one year from the date the legislation was signed into law (October 3, 2008). As a result, the provisions apply to new contracts and renewals on or after October 3, 2009.

• For groups with plan year benefits, the parity changes will take effect on the first renewal after
  10/3/2009. For groups with calendar year benefits, the parity benefits will take effect on a January 1, 2010 purchase or renewal.
• For collective bargaining agreement plans, the effective date is the later of January 1, 2010 or
  the date the collective bargaining agreement expires.

11. Are self-insured (ASO) groups included?

Yes. Self-insured groups (ASO), which are typically exempt from state regulations, are subject to the federal mental health parity legislation. These plans were previously subject to the 1996 federal parity law and are now included in this new legislation.

12. What are the cost implications of this act for an ASO group?

Actuarial analyses conducted both internally and externally estimate the cost impact for employers that currently comply with state parity mandates to be in the 0.2 – 2% range.The primary external source for this information is a Milliman Actuarial Study4, which projects cost increases of 0.1% to 0.6% depending on the level of management in place. The Congressional Budget Office has projected an average increase of 0.4% for plans. Please note that the figures in the Milliman study do reflect a scenario in which the copay for a Behavioral Health provider changes from $25 to $10.

The magnitude of the cost impact will depend on several factors, including the group’s current costsharing, whether or not out-of-network benefits are currently excluded, and whether or not out-patient behavioral health services are currently managed.

Tags: Mental Health Parity Act, Mental Health Parity and Addiction Equity Act of 2008, Mental Health Parity and Addiction Equity Act of 2008 FAQ, Paul Wellstone and Pete Domencici Mental Health Parity and Addiction Equity Act of 2008

Q1: What is the new COBRA subsidy provision contained in the stimulus package signed by the President?

The stimulus package, which was enacted as the American Recovery and Reinvestment Act of 2009 (ARRA) temporarily reduces the premium for COBRA coverage for eligible individuals. COBRA (the Consolidated Omnibus Budget Reconciliation Act of 1985) allows certain people to extend employer-provided group health coverage, if they would otherwise lose the coverage due to certain events such as divorce or loss of a job.

Individuals who are eligible for COBRA coverage because of their own or a family member’s involuntary termination from employment that occurred from September 1, 2008 through December 31, 2009 and who elect COBRA, may be eligible to pay a reduced premium. Eligible individuals pay only 35% of the full COBRA premiums under their plans for up to 9 months. The employer (or other responsible entity) may recover the remaining 65% of the premium by taking the subsidy amount as a credit on its quarterly employment tax return. This premium reduction is generally available for continuation coverage under the Federal COBRA provisions, as well as for group health insurance coverage under state continuation coverage laws.

If the individual was offered Federal COBRA continuation coverage as a result of an involuntary termination of employment that occurred at any time from September 1, 2008 through Feburary 16, 2009, and that individual declined to take COBRA at that time, or elected COBRA and later discontinued it, he/she may have another opportunity to elect COBRA coverage and pay a reduced premium.
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Q2: What plans are subject to the premium reduction provisions?

The COBRA premium reduction provisions apply to all group health plans sponsored by private-sector employers or employee organizations (unions) subject to the COBRA rules under the Employee Retirement Income Security Act of 1974 (ERISA). They also apply to plans sponsored by State or local governments subject to the continuation provisions under the Public Health Service Act, and plans in the Federal Employee Health Benefits Program (FEHBP). The premium reduction is also available for group health insurance that is required by State law to provide comparable continuation coverage (such as “mini-COBRA”).
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Q3: Who is eligible to receive the COBRA premium reduction?

ARRA makes the premium reduction available for “assistance eligible individuals.” An Assistance Eligible Individual is a COBRA qualified beneficiary who meets the following requirements:
Is eligible for COBRA continuation coverage at any time during the period from September 1, 2008 through December 31, 2009;
Elects COBRA coverage (when first offered or during the additional election period provided by ARRA); and
The COBRA election opportunity relates to an involuntary termination of employment that occurred at some time from September 1, 2008 through December 31, 2009. However, if the individual is eligible for other group health coverage (such as through a new employer’s plan or a spouse’s plan) or Medicare he/she is not eligible for the premium reduction. If the employee’s termination of employment was for gross misconduct, the employee and any dependents generally would not qualify for COBRA or the premium reduction.

Electing the premium reduction disqualifies the individual for the Health Coverage Tax Credit. Additionally, certain high-income individual may have to repay the amount of the premium reduction through an increase in their income taxes. If the amount earned for the year is more than $125,000 (or $250,000 for married couples filing a joint federal income tax return), individuals may have to repay all or part of the premium reduction through an increase in their income tax liability for the year. For more information, visit the IRS web page on ARRA.
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Q4: Who is eligible for the second election opportunity for COBRA coverage?

Qualified beneficiaries whose qualifying event was an involuntary termination of employment during the period from September 1, 2008 through February 16, 2009 who did not elect COBRA when it was first offered OR who did elect COBRA but are no longer enrolled (for example, those who dropped COBRA coverage because they were unable to continue paying the premium) have a new, second election opportunity. Individuals eligible for the extended COBRA election period must receive a notice informing them of this opportunity. This notice must be provided by April 18, 2009 and individuals have 60 days after the notice is provided to elect COBRA. However, this special election period does not extend the period of COBRA continuation coverage beyond the original maximum period (generally 18 months from the employee’s involuntary termination). COBRA coverage elected in this special election period begins with the first period of coverage beginning on or after February 17, 2009.

Under ARRA, this special election period opportunity is not required to be provided with respect to State continuation coverage that is provided pursuant to State insurance law. A State can take action, however, to provide an additional election period in its continuation coverage program for individuals involuntarily terminated from September 1, 2008 through February 16, 2009 in order for them to request premium assistance based upon involuntary termination occurring during that period. For more information on rights and responsibilities regarding election periods under State law, contact your State insurance commissioner’s office or CMS.

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Q5: Does ARRA impose any new notice requirements?

Yes, plans and issuers are required to notify qualified beneficiaries regarding the premium reduction and other information about their rights under ARRA as follows:
A general notice to all qualified beneficiaries, whether they are currently enrolled in COBRA coverage or not, who have a qualifying event during the period from September 1, 2008 through December 31, 2009. This notice may be provided separately or with the COBRA election notice following a COBRA qualifying event.
A notice of the extended COBRA election period to any Assistance Eligible Individual (or any individual who would be an Assistance Eligible Individual if a COBRA continuation coverage election were in effect); who had a qualifying event at any time from September 1, 2008 through February 16, 2009; and who either did not elect COBRA continuation coverage or who elected but subsequently discontinued COBRA. This notice must be provided within 60 days following February 17, 2009. Unless specifically modified by ARRA, the existing COBRA notice manner and timing requirements continue to apply.

Under the State programs, the issuer of the group health plan must provide the notice to qualified beneficiaries with the information on how to apply for the premium reduction. These notices must be provided within the time required by State law.
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Q6: What information must the notices include?

The notices must include the following information:
The forms necessary for establishing eligibility for the premium reduction;
Contact information for the plan administrator or other person maintaining relevant information in connection with the premium reduction;

• A description of the second election period (if applicable to the individual);
• A description of the requirement that the Assistance Eligible Individual notify the plan when he/she becomes eligible for coverage under another group health plan or Medicare and the penalty for failing to do so;
• A description of the right to receive the premium reduction and the conditions for entitlement; and
  If offered by the employer, a description of the option to enroll in a different coverage option available under the plan.

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Q7: Has the DOL developed model notices?

Yes. The Department of Labor has developed model notices that are available.
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Q8: Can employees currently enrolled in COBRA continuation coverage switch to a different coverage option offered by the plan?

Yes. Group health plans are permitted, but not required, to allow qualified beneficiaries to enroll in coverage that is different than the coverage they had at the time of the qualifying event. ARRA provides that changing coverage will not cause an individual to be ineligible for the COBRA premium reduction, provided that:
The premium for the different coverage is the same or lower than the coverage the individual had at the time of the qualifying event;
The different coverage is also offered to active employees; and
The different coverage is not limited to only dental coverage, vision coverage, counseling coverage, a flexible spending account, or an on-site medical clinic.
If the plan permits individuals to change coverage options, the plan must provide the individuals with a notice of their opportunity to change. Individuals have 90 days to elect to change their coverage after the notice is provided.
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Q9: If the employee is required to pay only 35% of the premium, how is the employer reimbursed for the remaining 65% of the premium?

The employer (or other responsible entity) may recover the subsidy provided to Assistance Eligible Individuals by taking the subsidy amount as a credit on its IRS Form 941 quarterly employment tax return.
For more information on the Form 941 credit and the tax provisions in ARRA, visit the IRS web site.
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Q10: Does the premium reduction apply to premiums paid for periods of coverage prior to enactment of the ARRA?

No. There is no premium reduction for premiums paid for periods of coverage prior to February 17, 2009.
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Q11: If a plan receives payment of 100 percent of the premium for coverage for March or April from an individual determined to be eligible for the premium reduction, what does the plan do with the overpayment?

If an individual meets the requirements of an Assistance Eligible Individual and pays 100 percent of the premium in March or April for coverage in those months, the overpayment can be applied as a credit toward subsequent premiums as long as it can be used within 180 days of the overpayment. Otherwise, the overpayment must be reimbursed to the individual within 60 days of receipt.
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Q12: If the employer denies the employee’s request for the premium reduction does the employee have appeal rights?

Yes. Individuals who are denied treatment as Assistance Eligible Individuals and thus denied eligibility for the premium reduction may request an expedited review of the denial. The Department of Labor will handle appeals related to private sector employer plans subject to ERISA’s COBRA provisions. The Department of Health and Human Services will handle appeals for Federal, State, and local governmental employees, as well as appeals related to group health insurance coverage provided pursuant to state continuation coverage laws. The Departments must make a determination within 15 business days of receipt of a completed request for review. The Department of Labor is currently developing a process and an official application form that will be required to be completed for appeals. The process will include obtaining information from the employer, plan or insurer where appropriate. There will be a very short turn around time for submission of this information due to the short time for the determination.

Tags: ARRA, COBRA stimulus, Employer COBRA Stimulus FAQ

With an upcoming State House vote expected on the Health Insurance Consumer Protection Act (House Bill 3923), legislation establishing key reforms on health insurance in Illinois, AARP released the following letter to State Legislators today alerting them that the Association will record roll call votes on the bill, and inform its 1.8 million members in Illinois how their legislator voted.

According to exit polls, roughly 1 out of every 4 voters in the past election was a member of AARP. Nearly 100% of AARP members are registered to vote, while over 70% vote in every local, state and federal election.

“Illinoisans need and deserve to know where their State Senators and Representatives stand on the issues, and AARP will ensure they have that information on issues such as health insurance reform,” said Robert Gallo, AARP Illinois Senior State Director.

With record numbers of people losing their employer-based health insurance and now purchasing coverage in the private insurance market, the Health Insurance Consumer Protection Act, introduced by Representative Greg Harris, will establish several critical consumer protections. The Senate’s vote on the legislation will also be tracked and reported as it happens.

The legislation will:

• Require insurance companies to spend at least 75% of premium dollars on medical care rather than on executives’ salaries, marketing, and profits.
• Establish an Office of Consumer Health Insurance to conduct external independent reviews of denied claims and rate increases.
• Simplify the complicated application process for both individual and small group markets by creating a standard application, making it easierfor them to get coverage.

AARP is urging all legislators to pass the measure; getting the bill signed into law is a top priority for the Association.

Following are excerpts from the letter sent by Gallo to State Legislators:

“AARP members are looking to us to keep them informed about what issues are dominating the policy debates in Illinois and where their elected officials stand on these issues.

“Our members care deeply about fixing our broken health care system; including addressing the unfair and inconsistent practices in the private health insurance market. They want to know both how AARP is representing their concerns and how the Illinois State Legislature is responding to our efforts.

“We believe that people make the right choices when they understand the issues and the positions taken by their elected officials. People need and deserve to know where their Representatives and Senators stand on the issues that matter most.

“Therefore, AARP will be recording House and Senate roll call votes on key issues, and informing our Illinois members of the results of these key votes — and how their elected officials voted.

“AARP will track and report the upcoming House vote on House Bill 3923, the Health Insurance Consumer Protection Act, introduced by Representative Greg Harris. With record numbers of people losing their employer-based health insurance and now purchasing coverage in the private insurance market, the legislation will establish several critical consumer protections.

“The legislation will require insurance companies to spend at least 75% of premium dollars on medical care; establish the Office of Consumer Health Insurance to conduct external independent reviews of denied claims and rate increases; and simplify the application process for both individual and small group markets by creating a standard application.

“AARP strongly urges you to vote in favor of this legislation.”

Tags: aarp, AARP Illinois Insurance, Illinois Health Insurance News, Illinois Health Insurance Reform