Mental Health/Substance Abuse Benefits

On February 2, 2010, the federal government issued regulations that interpret the changes to the federal Mental Health Parity Act, which requires "parity" between the financial requirements and treatment limitations applied to medical or surgical benefits, and mental health and substance use disorder benefits. This law impacts group health plans, both fully insured and self-funded, with more than 50 total employees.  

On July 1, 2010, the federal government issued additional "safe harbor" guidance indicating that until it issues final regulations, federal agencies will establish an enforcement safe harbor under which they will not take enforcement action against a plan or issuer that divides its benefits for outpatient services into two sub-classifications for applying the financial requirement and treatment limitation rules under mental health parity law:office visits and  all other outpatient items and services. 

After the sub-classifications are established, the plan or issuer may not impose any financial requirement or treatment limitation on mental health or substance use disorder benefits in any sub-classification (that is, office visits or non-office visits) that is more restrictive than the predominant financial requirement or treatment limitation that applies to substantially all medical/surgical benefits in the sub-classification using the methodology set forth in the interim final rules issued February 2.  

This safe harbor guidance recognizes that it is common for benefit plans to apply a copayment for office visits (for example, physician or psychologist visits) but coinsurance for other outpatient services (for example, outpatient surgery, facility charges for day treatment centers, laboratory charges or other medical items), and, thus, provides an alternate method for evaluating outpatient services by testing office visits and all other outpatient services separately.