Consistency of Large Employer and Group Health Plan Benefits with Requirements of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Appendix A. Detailed Compliance Testing Results: Milliman Database (2010)

11/01/2013

  1. There were no plans in the Milliman sample that did not offer any MH/SUD benefits during 2009-2011.

  2. The percentage of plans with separate deductibles and/or out-of-pocket (OOP) maximums for MH/SUD in their 2010 benefit designs is as follows:

    • 3.2% of plans had separate deductibles for MH/SUD benefits. That is, MH/SUD member OOP costs did not accumulate towards a single deductible combined with their medical/surgical benefits.

    • 7.2% of plans had separate OOP maximums for MH/SUD and medical/surgical benefits.

    • 3.2% of plans had separate deductibles and separate OOP maximums for MH/SUD benefits and medical/surgical benefits.

    These separate MH/SUD deductibles and OOP maximums were removed such that the post-parity benefits had integrated deductibles and OOP maximums for MH/SUD and medical/surgical benefits.

  3. We were not able to identify any plan that increased medical/surgical financial requirements or eliminated certain coverage for MH/SUD disorders to achieve parity.

    The following sections present the testing results in tables that summarize the percentage of plans and the specific changes that had to be made to become parity compliant. There are tables for each classification of MH/SUD benefits as defined by the IFR (Inpatient In-Network, Inpatient Out-of-Network, Outpatient In-Network, Outpatient Out-of-Network, Emergency Care, and Prescription Drug (Rx). Results also report when the outpatient benefits safe harbor was used to separately test Outpatient Office Visits from Outpatient-Other benefits.

    Nearly all the tables have the identical format. The first column displays the type of quantitative financial requirement or treatment limitation applicable to the benefit classification in question. The subsequent columns summarize the percentage of plans where each type of financial requirement was unchanged, added, converted to a different type of cost-sharing, increased, decreased, or modified in other ways.

    • "No Change" shows the percentage of plans where no changes were required to become compliant with MHPAEA.

    • "Added" indicates the percentage of plans that did not have a certain type of financial requirement when one was allowed by MHPAEA, and had the option of adding one.

    • "Converted" indicates the percentage of plans that had to change the type of member cost-sharing. Typically, plans had to either switch from a dollar copay to the use of the deductible with coinsurance and OOP maximum structure, or vice versa.

    • "Removed" indicates the percentage of plans that had to completely remove the financial requirement (and were not allowed to convert it to a different form of cost-sharing).

    • "Increased" indicates the percentage of plans that were charging a lower cost-sharing (or OOP maximum) than was allowed by MHPAEA, and had the option of increasing it.

    • "Decreased" indicates the percentage of plans that were charging a higher cost-sharing (or OOP maximum) than was allowed by MHPAEA, and were required to reduce it.

    • "Exception" indications the percentage of plans that had to make changes that are not adequately described by any of the other options in the table.

    Please note that in several of the tables that describe cost-sharing changes (sub-section "a"), the percentages across rows may not sum to 100%. For example, in section 4a, the percentage of plans that did not have to make any changes to their deductible is 93.3% (second column). The percentage of plans that had to make a change to their deductible was 5.7% (sum of the next six columns). These two percentages sum to only 99.0%. The reason for this is that 1.0% of the plans had copays which had to be converted to a deductible/coinsurance structure. This conversion was counted under the "Converted" column of the copay line. To avoid double counting, they did not include these plans anywhere in the "Deductible" row, resulting in total percentages below 100%.

  4. Inpatient MH benefits.

    1. Copay/coinsurance/deductible/OOP maximum levels (quantitative financial requirements).

      The table below shows summarized results of compliance testing of the Inpatient In-Network Mental Health (IP INN MH) benefits.

      Percent of Plans Covering IP INN MH Services: 96.0%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1,2 93.3% 3.3% 0.0% 0.8% 0.0% 0.8% 0.8%
      OOP max1 91.7% 7.5% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay1 93.3% 2.5% 0.8% 0.8% 0.0% 1.7% 0.0%
      Coinsurance1 92.5% 0.0% 0.8% 0.0% 0.0% 5.8% 0.0%
      1. Note that some percentages do not add up to 100%. The difference is due to plans where deductible, coinsurance, and OOP max were added to replace a copay or vice versa. These conversions are recorded under the row that represents the original cost-sharing.
      2. Indicated exceptions include plans where a partial hospital benefit deductible was removed but could be replaced by a per admit deductible with coinsurance up to OOP max.

      Over 90% of the plans that provided IP INN MH benefits did not have to make any changes to their financial requirements to comply with MHPAEA and the IFR.

      About 7.5% of the plans were required to accumulate the member OOP payments for these benefits towards the same OOP maximum that was applicable to medical/surgical benefits.

      Nearly 6% of the plans were required to reduce their coinsurance on this benefit to be parity compliant.

      The table below shows summarized results of the compliance testing of the Inpatient Out-of-Network Mental Health (IP OON MH) benefits.

      Percent of Plans Covering IP OON MH Services: 82.4%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1 99.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.0%
      OOP max 92.2% 7.8% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance 94.2% 0.0% 0.0% 0.0% 0.0% 5.8% 0.0%
      1. Indicated exceptions include plans where a partial hospital benefit deductible was removed but could be replaced by a per admit deductible with coinsurance up to OOP max.

      Over 90% of the plans that provided IP OON MH benefits did not have to make any changes to their cost-sharing to comply with MHPAEA and the IFR.

      About 8% of the plans were required to accumulate the member out-of-payments for these benefits towards the same OOP maximum that was applicable to corresponding medical/surgical benefits.

      Nearly 6% of the plans were required to reduce their coinsurance on this benefit to be parity compliant.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans that had to remove various QTLs placed on their IP INN MH benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed 12.5%
      Percent of plans where visit limits were removed N/A
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 4.2%

      The most common IP INN MH treatment limitation removed was the day limit in a calendar year on inpatient stays (12.5% of the plans).

      Other changes that certain plans had to make to their IP INN MH benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Day limits were removed for Inpatient In-Network RTF services only   0.8%

      The following table summarizes the percentage of plans that had to remove various QTLs placed on their IN OON MH benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed 6.8%
      Percent of plans where visit limits were removed N/A
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 4.9%

      The most common IP OON MH treatment limitation removed was the day limits in a calendar year on inpatient stays (6.8% of the plans).

      Other changes that certain plans had to make to their IP OON MH benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Plans where day limits were removed for Inpatient Out-of-Network RTFs only 1.9%
      Plans where out-of-network benefits were previously not covered, but were recommended they be added to comply with the cover one, cover all classification requirement 2.9%

      For precertification requirements and penalties for lack of precertification, please see section 13.

  5. Inpatient SUD benefits.

    1. Copay/coinsurance/deductible/OOP maximum levels (quantitative financial requirements).

      The table below shows summarized results of the compliance testing of the Inpatient In-Network Substance Use Disorder (IP INN SUD) benefits.

      Percent of Plans Covering IP INN SUD Services: 95.2%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1,2 93.3% 3.4% 0.0% 0.8% 0.0% 0.8% 0.8%
      OOP max1 91.6% 7.6% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay1 93.3% 2.5% 0.8% 0.8% 0.0% 1.7% 0.0%
      Coinsurance1 92.4% 0.0% 0.8% 0.0% 0.0% 5.9% 0.0%
      1. Note that some percentages do not add up to 100%. The difference is due to plans where deductible, coinsurance, and OOP max were added to replace a copay or vice versa. These conversions are recorded under the line that represents the original cost-sharing.
      2. Indicated exceptions include plans where a partial hospital benefit deductible was removed but could be replaced by a per admit deductible with coinsurance up to OOP max.

      Over 90% of the plans that provided Inpatient IP INN SUD benefits did not have to make any changes to their financial requirements to comply with MHPAEA and the IFR.

      About 7.6% of the plans were required to accumulate the member OOP payments for these benefits towards the same OOP maximum that was applicable to medical/surgical benefits.

      Nearly 6% of the plans were required to reduce their coinsurance on this benefit to be parity compliant.

      The table below shows summarized results of the compliance testing of the Inpatient Out-of-Network Substance Use Disorder (IP OON SUD) benefits.

      Percent of Plans Covering IP OON SUD Services: 82.4%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1,2 99.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.0%
      OOP max1 91.3% 8.7% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay1 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance1 94.2% 0.0% 0.0% 0.0% 0.0% 5.8% 0.0%
      1. Indicated exceptions include plans where a partial hospital benefit deductible was removed but could be replaced by a per admit deductible with coinsurance up to OOP max.

      Over 90% of the plans that provided IP OON SUD benefits did not have to make any changes to their financial requirements to comply with MHPAEA and the IFR.

      About 8.7% of the plans were required to accumulate the member OOP payments for these benefits towards the same OOP maximum that was applicable to medical/surgical benefits.

      Nearly 6% of the plans were required to reduce their coinsurance on this benefit to be parity complaint.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans that had to remove various QTLs placed on their IP INN SUD benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed 19.3%
      Percent of plans where visit limits were removed N/A
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 6.7%

      The most common IP INN SUD treatment limitation removed was the day limit in a calendar year on inpatient stays (19.3% of plans).

      Other changes that certain plans had to make to their IP INN SUD benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Day limits were removed for Inpatient In-Network RTFs only 0.8%
      Inpatient Detoxification Days are covered but Inpatient Rehabilitation Days are not covered1   2.5%
      1. This is a scope of services issue which plans could ignore if they so choose

      The following table summarizes the percentage of plans that had to remove various QTLs placed on their IN OON SUD benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed 15.5%
      Percent of plans where visit limits were removed N/A
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 6.8%

      The most common out IP OON SUD treatment limitation removed was the day limits in a calendar year on inpatient stays (15.5% of plans).

      Other changes that certain plans had to make to their IP OON SUD benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Plans where day limits were removed for Inpatient Out-of-Network RTFs 1.9%
      Plans where IN OON SUD benefits were previously not covered but should be under the cover one, cover all classification requirements   2.9%
      Inpatient Detoxification Days are covered but Inpatient Rehabilitation Days are not covered1 2.9%
      1. This is a scope of services issue which plans could ignore if they so choose

      For precertification requirements and penalties for lack of precertification, please see section 13.

      About 8% of the plans were tested without making use of the safe harbor provision provided by the IFR. The remaining plans were tested using the safe harbor provision. The safe harbor has implications for how many benefit classifications can be created for parity compliance testing purposes. Prior to the safe harbor provision, there was only one outpatient classification for in-network benefits and a separate one for out-of-network benefits. The safe harbor allows splitting of the outpatient classifications into office visits and outpatient-other sub-classifications. Sections 6 and 7 present the compliance testing results for plans that were tested without the safe harbor. Sections 8 through 11 present the results for plans tested with the safe harbor. Sections 8 and 9 show the results for the Outpatient Office Visit benefit sub-classification, while sections 10 and 11 show the results for the Outpatient Other sub-classification.

  6. Outpatient MH benefits.

    1. Copay/coinsurance/deductible/OOP maximum levels (quantitative financial requirements).

      The table below shows summarized results of the compliance testing of the Outpatient In-Network Mental Health (OP INN MH) benefits.

      Percent of Plans covering OP INN MH Services -- Tested Without Safe Harbor: 8.0%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      OOP max 70.0% 30.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

      Only 8% of all plans provided OP INN MH benefits and were tested without making use of the safe harbor provision. Most of them were compliant with MHPAEA and the IFR; 30% of these plans required only one notable change to become compliant -- these plans were required to subject the OP INN MH benefits to the predominant medical/surgical OOP maximum.

      The table below shows summarized results of the compliance testing of the Outpatient Out-of-Network Mental Health (OP OON MH) benefits.

      Percent of Plans Covering OP OON MH Services -- Tested Without Safe Harbor: 17.6%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      OOP max 90.9% 9.1% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance 90.9% 0.0% 0.0% 0.0% 0.0% 9.1% 0.0%

      Only about 18% of all plans provided OP OON MH benefits and were tested without making use of the safe harbor. Nearly all of them were compliant. The only notable changes that needed to be made to a few of the plans to become compliant was subjecting the OP OON MH benefits to the predominant medical/surgical OOP maximum, and reducing the coinsurance applicable to these services to the predominant medical/surgical coinsurance level.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans tested without the Outpatient safe harbor that had to remove various QTLs placed on their OP INN MH benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 50.0%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 0.0%

      The most common OP INN MH treatment limitation removed was the calendar year visit limits on outpatient professional visits (50% of the plans tested without safe harbor).

      The following table summarizes the percentage of plans tested without the Outpatient safe harbor that had to remove various QTLs placed on their OP OON MH benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 13.6%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 0.0%

      The most common OP OON MH treatment limitation removed was the calendar year visit limits on outpatient professional visits (13.6% of the plans tested without safe harbor).

      Other changes that certain plans tested without the Outpatient safe harbor had to make to their OP OON MH benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Plans where OP OON MH benefits were previously not covered but were recommended be covered under the cover one, cover all classification requirement   13.6%

      For precertification requirements and penalties for lack of precertification, please see section 13.

  7. Outpatient SUD.

    1. Copay/coinsurance/deductible/OOP maximum levels (quantitative financial requirements).

      The table below shows summarized results of the compliance testing of the Outpatient In-Network Substance Use Disorder (OP INN SUD) benefits.

      Percent of Plans Covering OP INN SUD Services -- Tested Without Safe Harbor: 8.0%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      OOP max 70.0% 30.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

      Only 8% of all plans provided OP INN SUD benefits and were tested without making use of the safe harbor. Most of them were compliant. The only notable change that was needed to become compliant was subjecting the OP INN SUD benefits to the predominant medical/surgical OOP maximum; 30% of these plans needed this change.

      The table below shows summarized results of the compliance testing of the Outpatient Out-of-Network Substance Use Disorder (OP OON SUD) benefits. Approximately 18% of the plans provided this benefit.

      Percent of Plans Covering OP OON SUD Services and Were Tested Without Safe Harbor: 17.6%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      OOP max 90.9% 9.1% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance 90.9% 0.0% 0.0% 0.0% 0.0% 9.1% 0.0%

      Only 18% of all plans offered OP OON SUD benefits and were tested without making use of the safe harbor. Nearly all of them were compliant. The only notable changes that were needed to become compliant was subjecting the OP OON SUD benefits to the predominant medical/surgical OOP maximum, and reducing the coinsurance applicable to these services to the predominant medical/surgical coinsurance level.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans tested without the safe harbor that had to remove various QTLs placed on their OP INN SUD benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 50.0%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 30.0%

      The calendar year professional visit limits for OP INN SUD benefits were removed from 50% of the plans, and calendar year dollar limits were removed for these services from 30% of the plans.

      The following table summarizes the percentage of plans tested without the safe harbor that had to remove various QTLs placed on their OP OON SUD benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 63.6%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 9.1%

      The most common treatment limitation removed was the calendar year professional visit limits on OP OON SUD visits (64% of the plans). Calendar year dollar limits were removed in 9% of the plans.

      Other changes that certain plans had to make to their OP OON SUD benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Plans where OP OON SUD benefits were previously not covered but plans were advised to cover it under the cover one, cover all requirement   13.6%

      For precertification requirements and penalties for lack of precertification, please see section 13.

  8. Outpatient office visits for MH disorders.

    1. Copay/coinsurance/deductible/OOP maximum levels (quantitative financial requirements).

      The table below shows summarized results of the compliance testing of the Outpatient Office Visit In-Network Mental Health (OP OV INN MH) benefits.

      Percent of Plans Covering OP OV INN MH Benefits -- Tested with Safe Harbor: 88.0%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1 94.5% 0.9% 0.0% 3.6% 0.0% 0.0% 0.0%
      OOP max1 99.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay1,2,3 76.4% 0.0% 0.9% 2.7% 0.0% 6.4% 6.4%
      Coinsurance1,4 89.1% 0.0% 7.3% 0.9% 0.0% 0.9% 0.9%
      1. Note that some percentages do not add up to 100%. The difference is due to plans where deductible, coinsurance, and OOP max were added to replace a copay or vice versa. These conversions are recorded under the line that represents the original cost-sharing.
      2. Indicated exceptions include plans that reduced OP OV INN MH copays only for specialist visits.
      3. Indicated exceptions include plans where plans were advised they could increase the OP OV INN MH copay to the specialist level.
      4. Indicated exceptions include plans were advised to change coinsurance to copay for "other services in physician office".

      Over 75% of the plans that provided OP OV INN MH benefits did not have to make any changes to their financial requirements to comply with MHPAEA and the IFR.

      About 6% of the plans were required to reduce their OP OV INN MH copays.

      Over 7% of the plans were required to convert their coinsurance to copays for this benefit category.

      The table below shows summarized results of the compliance testing of the Outpatient Office Visit Out-of-Network Mental Health (OP OV OON MH) benefits.

      Percent of Plans Covering OP OV OON MH Benefits -- Tested with Safe Harbor: 64.8%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      OOP max 91.4% 8.6% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 98.8% 0.0% 0.0% 0.0% 0.0% 1.2% 0.0%
      Coinsurance 92.6% 0.0% 0.0% 0.0% 0.0% 7.4% 0.0%

      Over 90% of the plans that provided OP OV OON MH benefits did not have to make any changes to their financial requirements to comply with MHPAEA and the IFR.

      About 9% were required to accumulate the member OOP payments for these OP OV OON MH benefits towards the same OOP maximum that was applicable to medical/surgical benefits.

      Over 7% of plans were required to reduce their coinsurance that was application to this benefit category.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans that were tested with the safe harbor that had to remove various QTLs placed on their OP OV INN MH benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 11.8%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 4.5%

      The most common treatment limitation removed was the calendar year professional visit limits on OP OV INN MH benefits (12% of plans). Nearly 5% of these plans had to remove calendar year dollar limits for these benefits.

      The following table summarizes the percentage of plans that were tested with the safe harbor that had to remove various QTLs placed on their OP OV OON MH benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 14.8%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 6.2%

      The most common treatment limitation removed was the calendar year professional visit limits on OP OV OON MH benefits (15% of plans). Nearly 6% of the plans had to remove calendar year dollar limits.

      Other changes that certain plans had to make to their OP OV OON MH benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Plans where OP OV OON MH benefits were previously not covered but were recommended be covered under the cover one, cover all classification requirement 3.7%

      For precertification requirements and penalties for lack of precertification, please see section 13.

  9. Outpatient office visits for SUD.

    1. Copay/coinsurance/deductible/OOP maximum levels.

      The table below shows summarized results of the compliance testing of the Outpatient Office Visit In-Network Substance Use Disorder (OP OV INN SUD) benefits. Approximately 87% of the plans provided this benefit.

      Percent of Plans Covering OP OV INN SUD Benefits -- Tested with Safe Harbor: 87.2%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1 91.7% 0.9% 0.0% 6.4% 0.0% 0.0% 0.0%
      OOP max1 99.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay1,2,3 77.1% 0.0% 0.9% 0.9% 0.0% 5.5% 7.3%
      Coinsurance1,4 87.2% 0.0% 8.3% 2.8% 0.0% 0.9% 0.0%
      1. Note that some percentages do not add up to 100%. The difference is due to plans where deductible, coinsurance, and OOP max were added to replace a copay or vice versa. These conversions are recorded under the line that represents the original cost-sharing.
      2. Indicated exceptions include plans that reduced copays only for specialist visits.
      3. Indicated exceptions include plans where plans were advised they could increase office visit copay to the specialist level.
      4. Indicated exceptions include plans where plans were advised to change coinsurance to copay for "other services in physician office".

      Over 75% of the plans that provided OP OV INN SUD benefits did not have to make any changes to their financial requirements to comply with MHPAEA and the IFR.

      About 6% of the plans were required to remove calendar year deductibles from this benefit category.

      About 5.5% of the plans were required to reduce their copays for these benefits. An additional 7% of the plans could increase their OP OV INN SUD copays on specialist services without violating parity, or were required to change from coinsurance to copays for any physician services other than regular outpatient office visits.

      Over 8% of the plans were required to convert their coinsurance to copays for these benefits.

      The table below shows summarized results of the compliance testing of the Outpatient Office Visit Out-of-Network Substance Use Disorder (OP OV OON SUD) benefits. Approximately 65% of the plans provided this benefit.

      Percent of Plans Covering OP OV OON SUD Benefits -- Tested with Safe Harbor: 64.8%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible 98.8% 0.0% 0.0% 1.2% 0.0% 0.0% 0.0%
      OOP max 90.1% 9.9% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 98.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance 93.8% 0.0% 1.2% 0.0% 0.0% 4.9% 0.0%

      Over 90% of the plans that provided OP OV OON SUD benefits did not have to make any changes to their financial requirements to comply with MHPAEA and the IFR.

      About 10% were required to accumulate the member OOP payments for these benefits towards the same OOP maximum that was applicable to medical/surgical benefits.

      Nearly 5% of the plans were required to reduce their coinsurance percentage that was application to this benefit category.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans tested with the safe harbor that had to remove various QTLs placed on their OP OV INN SUD benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 20.2%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 4.6%

      The most common in-network treatment limitation removed was the visit limits on OP OV INN SUD benefits (20% of plans). Nearly 5% of these plans had to remove calendar year dollar limits for these benefits.

      The following table summarizes the percentage of plans tested with the safe harbor that had to remove various QTLs placed on their OP OV OON SUD benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 14.8%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 6.2%

      The most common out-of-network treatment limitation removed was the visit limits on OP OV OON SUD benefits (15% of plans). Nearly 6% of these plans had to remove calendar year dollar limits for these benefits.

      Other changes that certain plans had to make to their OP OV OON SUD benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Plans where OP OV OON SUD benefits were previously not covered but were recommended be covered under the cover one, cover all requirement   3.7%

      For precertification requirements and penalties for lack of precertification, please see section 13.

  10. Outpatient other benefits for MH disorders.

    1. Copay/coinsurance/deductible/OOP maximum levels.

      The table below shows summarized results of the compliance testing of Outpatient-Other In-Network Mental Health (OP-Other INN MH) benefits.

      Percent of Plans Covering OP-Other INN MH Services -- Tested with Safe Harbor: 88.0%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1 74.5% 2.7% 0.0% 8.2% 0.0% 0.0% 0.0%
      OOP max1 79.1% 3.6% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 73.6% 0.0% 17.3% 7.3% 0.0% 1.8% 0.0%
      Coinsurance1 68.2% 0.0% 0.0% 10.0% 0.0% 4.5% 0.0%
      1. Note that some percentages do not add up to 100%. The difference is due to plans where deductible, coinsurance, and OOP max were added to replace copays or vice versa. These conversions are recorded under the line that represents the original cost-sharing.

      Nearly 70% of the plans that provided OP-Other INN MH benefits did not have to make any changes to their cost-sharing to comply with MHPAEA and the IFR.

      Over 17% of the plans were required to convert their copays to coinsurance for this benefit category, and over 7% had to remove copays completely

      10% of the plans were required to remove the coinsurance completely on this benefit, while another 4.5% of the plans were required to reduce the coinsurance level.

      The table below shows summarized results of the compliance testing of OP-Other Out-of-Network Mental Health (OP-Other OON MH) benefits.

      Percent of Plans Covering OP-Other OON MH Services -- Tested with Safe Harbor: 64.8%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1 95.1% 0.0% 0.0% 3.7% 0.0% 0.0% 0.0%
      OOP max 91.4% 8.6% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 98.8% 0.0% 1.2% 0.0% 0.0% 0.0% 0.0%
      Coinsurance1 88.9% 0.0% 0.0% 1.2% 0.0% 8.6% 0.0%
      1. Note that some percentages do not add up to 100%. The difference is due to plans where deductible, coinsurance, and OOP max were added to replace copays or vice versa. These conversions are recorded under the line that represents the original cost-sharing.

      Over 90% of the plans that provided OP-Other OON MH benefits did not have to make any changes to their cost-sharing to comply with MHPAEA and the IFR.

      Nearly 9% were required to accumulate the member payments for these benefits towards the same OOP maximum that was applicable to medical/surgical benefits.

      Nearly 9% of the plans were required to reduce their coinsurance that was application to this benefit category.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans tested with the safe harbor that had to remove various QTLs placed on their OP-Other INN MH benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 8.2%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 4.5%

      The most common treatment limitation removed was the visit limits on OP-Other INN MH benefits (8% of plans). Nearly 5% of the plans had to remove dollar limits.

      The following table summarizes the percentage of plans tested with the safe harbor that had to remove various QTLs placed on their OP-Other Out-of-Network Mental Health benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 9.9%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 6.2%

      The most common treatment limitation removed was the visit limits on OP-Other OON MH benefits (10% of plans). Nearly 6% of the plans had to remove dollar limits.

      Other changes that certain plans had to make to their OP-Other OON MH benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Plans where OP-Other OON MH Disorder benefits were previously not covered but were recommended be covered under the cover one, cover all requirement 3.7%

      For precertification requirements and penalties for lack of precertification, please see section 13.

  11. Outpatient other benefits for SUD.

    1. Copay/coinsurance/deductible/OOP maximum levels.

      The table below shows summarized results of the compliance testing of the Outpatient-Other In-Network Substance Use Disorder (OP-Other INN SUD) benefits.

      Percent of Plans Covering Op-Other INN SUD Services -- Tested with Safe Harbor: 87.2%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1 78.0% 2.8% 0.0% 8.3% 0.0% 0.0% 0.0%
      OOP max1 82.6% 3.7% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 77.1% 0.0% 13.8% 7.3% 0.0% 1.8% 0.0%
      Coinsurance1 70.6% 0.0% 0.0% 8.3% 0.0% 7.3% 0.0%
      1. Note that some percentages do not add up to 100%. The difference is due to plans where deductible, coinsurance, and OOP max were added to replace a copay or vice versa. These conversions are recorded under the line that represents the original cost-sharing.

      Over 70% of the plans that provided OP-Other INN SUD benefits did not have to make any changes to their cost-sharing to comply with MHPAEA and the IFR.

      About 8% of the plans were required to remove deductibles from this benefit category, while 3% of the plans were not subjecting these benefits to a deductible but could do so without violating parity.

      Nearly 14% of the plans were required to convert their copays to coinsurance, and another 7% had to completely remove copays from this benefit.

      About 7% of the plans were required to reduce their coinsurance, while another 8% had to completely remove coinsurance from this benefit.

      The table below shows summarized results of the compliance testing of the Outpatient-Other Out-of-Network Substance Use Disorder (OP-Other OON SUD) benefits.

      Percent of Plans Covering OP-Other OON SUD Services -- Tested with Safe Harbor: 64.8%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible 96.3% 0.0% 0.0% 3.7% 0.0% 0.0% 0.0%
      OOP max 90.1% 9.9% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance 92.6% 0.0% 0.0% 1.2% 0.0% 6.2% 0.0%

      Over 90% of the plans that provided OP-Other OON SUD benefits did not have to make any changes to their cost-sharing to comply with MHPAEA and the IFR.

      About 4% of the plans were required to remove deductibles from OP-Other OON SUD benefits.

      Nearly 10% were required to accumulate the member payments for these benefits towards the same OOP maximum that was applicable to the corresponding medical/surgical benefits; over 6% of the plans were required to reduce their coinsurance that was applied to this benefit category.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans that were tested with the safe harbor that had to remove various QTLs placed on their OP-Other INN SUD benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 16.5%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 4.6%

      The most common in-network treatment limitation removed was the visit limits on OP-Other INN SUD benefits (17% of plans). Nearly 5% of the plans had to remove dollar limits on OP-Other INN SUD benefits.

      The following table summarizes the percentage of plans that were tested with the safe harbor that had to remove various QTLs placed on their Outpatient-Other Out-of-Network Substance Use Disorder benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where day limits were removed N/A
      Percent of plans where visit limits were removed 9.9%
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 6.2%

      The most common treatment limitation removed was the visit limits on OP-Other OON SUD benefits (10% of plans). Nearly 6% of the plans had to remove dollar limits on OP-Other OON SUD benefits.

      Other changes that certain plans had to make to their OP-Other OON SUD benefits to become parity compliant are listed below.

        Exceptions     Plans (%)  
      Plans where OP-Other OONSUD benefits were previously not covered but were recommended be covered under the cover one, cover all requirement   3.7%

      For precertification requirements and penalties for lack of precertification, please see section 13.

  12. Emergency Care, including true emergency and non-emergent care provided in ERs -- MH and SUD benefits.

    1. Copay/coinsurance/deductible/OOP maximum levels.

      The table below shows summarized results of the compliance testing of ER MH/SUD benefits. 100% of the plans provided this benefit.

      Percent of Plans Covering ER MH/SUD Services: 100.0%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible1 94.4% 2.4% 0.0% 1.6% 0.0% 0.0% 1.6%
      OOP max 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay1 92.8% 2.4% 0.0% 0.0% 0.0% 0.0% 1.6%
      Coinsurance1,2 80.8% 0.0% 3.2% 1.6% 0.0% 1.6% 12.8%
      1. Indicated exceptions include plans where cost-sharing was reduced for ambulance only.
      2. Indicated exceptions include plans were only professional services cost-sharing was reduced.

      Over 80% of the plans that provided ER MH/SUD benefits did not have to make any changes to their cost-sharing to comply with MHPAEA and the IFR.

      Over 2% of the plans could subject their ER MH/SUD benefits to a deductible without violating parity but were previously not doing so, while another 2% were required to remove deductibles altogether from these benefits.

      Over 2% of the plans could apply a copay to these benefits without violating parity but were previously not doing so.

      Over 3% of the plans were required to convert their coinsurance to copays, another 1.6% had to completely remove the coinsurance, and another 1.6% had to reduce the coinsurance levels applicable to this benefit. 13% of the plans were required to reduce their coinsurance on professional services only.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans that had to remove various QTLs placed on their ER MH/SUD benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where visit limits were removed 0.0%
      Percent of plans where (annual) dollar limits were removed   0.0%

      As shown above, no treatment limits applied to the ER MH/SUD benefits.

      Certain plans were non-compliant with MHPAEA and the IFR in ways other than those described above.

        Exceptions     Plans (%)  
      Percent of plans where non-emergency use of ER had different cost-sharing than for true emergencies 10.4%
      Percent of plans where out-of-network ER cost-sharing had to be changed to be the same as in-network ER cost-sharing 28.0%
      Percent of plans where members were required to pay the amount above the allowed charge for out-of-network behavioral health emergency services in a non-parity compliant way 0.8%

       

  13. Rx -- MH and SUD benefits.

    1. Copay/coinsurance/deductible/OOP maximum levels.

      The table below shows summarized results of the compliance testing of MH/SUD Rx benefits; 99% of the plans provided this benefit.

      Percent of Plans Covering MH/SUD Rx: 99.2%
        Cost-Sharing     No Change     Added     Converted     Removed     Increased     Decreased     Exception  
      Deductible 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      OOP max 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Copay 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
      Coinsurance 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

      100% of the plans that provided MH/SUD Rx benefits did not have to make any changes to their cost-sharing to comply with MHPAEA and the IFR.

    2. Quantitative treatment limitations.

      The following table summarizes the percentage of plans that had to remove various QTLs placed on their MH/SUD Rx benefits.

        Service/Dollar Limitations     Plans (%)  
      Percent of plans where quantity limits were removed   0.0%
      Percent of plans where dollar limits were removed 0.0%

      As shown above, no limits applied to the MH/SUD Rx benefits.

      Certain plans were non-compliant with MHPAEA and the IFR in ways other than those described above.

        Exceptions     Plans (%)  
      Percent of plans with different cost-sharing for preferred vs. non-preferred pharmacies. Plans were advised to consult with legal counsel.   18.5%
      Percent of plans where only 3 smoking cessation drugs are covered. 2.4%
      Percent of plans that had a supply limit on smoking cessation drugs/supplies. 21.0%

      The IFR does not specify that having different Rx cost-sharing for preferred vs. non-preferred pharmacies is compliant. Therefore, a strict interpretation of only having a single Rx benefit classification implies that this cost-sharing structure for MH and SUD drugs would be non-compliant.

      However, Milliman did receive additional informal guidance on this manner that this strict interpretation was not the intent of the sponsoring Departments. The IFR states that "if a plan or issuer applies different levels of financial requirements to different tiers of Rx benefits based on reasonable factors (determined in accordance with the NQTL rules) and without regard to whether a drug is generally prescribed for medical/surgical benefits or MH/SUD benefits, then the plan or issuer satisfies the substantially all/predominant test". Here, if the differences in financial requirements are considered to be based on reasonable factors (discounts for preferred pharmacies), then the tests are satisfied. Therefore, the 18.5% of plans who are reported to be in violation of parity in the table above would not be out of compliance. Hopefully, additional formal guidance will be provided on this issue.

  14. Non-quantitative treatment limitations.

    The following table describes the NQTLs that were found in various plans in the Milliman database. These limitations appear to be non-compliant with MHPAEA and the IFR.

    NQTL Description   % of Plans  
    MH/SUD precertification requirements were more stringent than for medical/surgical benefits. 28.2%
    Pre-approval was required starting with the 13th OP OV MH visit. 1.8%
    The external/expedited fees charged to appeal a service denial for treatment of a mental condition were higher than for medical/surgical conditions. 4.5%
    No MH/SUD benefits were provided outside the state of residence but medical/surgical benefits were. 0.9%
    Some smoking cessation benefits were covered in one or more benefit classifications but not in all benefit classifications that covered medical/surgical benefits. 12.7%
    Medical necessity was applied to MH/SUD benefits but not to medical/surgical benefits. 8.2%
    Out-of-network treatment was covered only if in-network treatment was unavailable. This applied only to MH/SUD benefits. 0.9%
    Plans imposed a probationary period only for substance abuse treatment. 0.9%
    Smoking cessation drugs were only covered on a mail-order basis. 0.9%
    Out-of-network eating disorder treatment was covered only if in-network services were unavailable; no such requirement applied to OON medical/surgical benefits. 0.9%
    Plans did not include smoking cessation for dependent children. 2.7%

    In addition to the NQTLs listed above, other plan design features which have not been previously mentioned which plans should consider regarding MHPAEA compliance. These changes include removal of QTLs that are not mentioned in the sections above.

    Other Treatment Limitations   % of Plans  
    Plans placed limits on professional counseling for tobacco use/smoking 24.5%
    Plans placed a benefit limit on early intervention services which includes psychological counseling. 0.9%
    Plans imposed a dollar penalty for not getting pre-approval for inpatient MH/SUD admissions, and no such penalty applied to inpatient medical/surgical benefits. 0.9%
    Inpatient SUD services are covered but limited to detoxification. No change was recommended to plan design because this situation is currently allowed under the "scope of services" provision in MHPAEA. 2.7%
     

 

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