According to the regulations, NQTLs limit the scope or duration of benefits and can include, but are not limited to, plan provisions related to:
- Medical management,
- Rx formulary,
- Provider admission in a network,
- Determination of UCR amounts,
- Step-therapy requirements, and
- Conditioning benefits on completion of a course of treatment.
Any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits must be comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors applied to medical/surgical benefits. However, these requirements allow variations to the extent that recognized clinically appropriate standards of care may permit a difference.
In order to assess compliance with the MHPAEA regulations, NQTLs processes in place for MH/SUD and medical/surgical benefits were evaluated. NQTL assessments were conducted for self-insured programs when requested by an employer. In 2010, NQTL assessments were completed for 22 different employers, representing 17 different medical and MH/SUD vendors. All employers were national employers with at least 1,000 employees. The majority of employers (72%) for whom NQTL assessments completed were large employers with 10,000 or more employees.
When the MHPAEA regulations were released, many health plans and behavioral health care organizations assured employers that they would conduct an analysis of their program procedures and, if identified, would implement the necessary changes to ensure compliance with MHPAEA regulations. As NQTL analyses were completed for only 22 employers, we can only assume that most employers relied on the health plans and behavioral health care organizations to conduct the NQTL analysis and make any necessary changes to comply with the regulations.
Employers participating in the analysis review did so for a number of reasons, including:
Recognized that the employer is ultimately responsible for plan compliance due to the self-insured status of the plan and wanted to engage with an objective third party to conduct the analysis; and/or
Required written documentation of the assessment process, results, and outcomes.
In the process of conducting the analyses, we evaluated medical/surgical and MH/SUD procedures in place for most of the major medical and behavioral health care organizations in the country. As we communicated our findings to these organizations, issues identified as potential areas of non-compliance could be addressed and our recommendations could be applied across the vendors' book-of-business. As a result, it is likely that the analyses conducted for the 22 employers helped to shape the vendor response to and compliance with the regulations.
Each vendor that administered an employer's medical and MH/SUD benefit plans was requested to respond to an extensive questionnaire that collected details about the vendor's NQTL processes and procedures in place in 2010. Information was collected on both medical/surgical and MH/SUD procedures. Any differences between the vendor's standard procedures and employer-specific procedures were noted. We also requested each employer's Rx vendor to respond to specific questions regarding NQTLs related to medical and MH/SUD Rx benefits.
Once the questionnaire was completed, we reviewed vendor responses and conducted a detailed comparison of the processes and procedures that were in place for medical/surgical and for MH/SUD. The following areas were reviewed:
- Procedures and services requiring precertification
- Responsibility for precertification (provider or member)
- Documentation required
- Medical necessity review conducted
- Guidelines used
- Concurrent Review
- Levels of care considered for review
- Source of guidelines
- Frequency of reviews
- Discharge Planning
- Frequency of reviews
- Follow-up after discharge
- Case Management
- Case identification process
- Case management process
- Retrospective Review
- Services included
- UCR Determination
- Data source
- Frequency of updates
- Provider Network Admission
- Credentialing process and requirements
- Timing to complete credentialing process
- Ongoing monitoring
- Re-credentialing frequency
- Performance Networks
- Specialties included
- Network model
- Reimbursement Rates
- Experimental and Investigational
Each process and procedure was compared to determine which, if any, were more stringent for MH/SUD than they were for medical/surgical. Any procedures or requirements that could be considered to be more stringent for MH/SUD than medical/surgical were identified as potentially non-compliant with the MHPAEA regulations.
Results of the assessment were communicated to the employer as well as to each vendor involved in the assessment process. Discussions were held between the employer and each vendor to review the findings and determine the appropriate and necessary actions to comply with MHPAEA regulations.
Areas of Potential Non-Compliance
Our initial review identified many areas that were deemed potentially non-compliant. However, after further investigation and follow-up documentation from the vendors, it was determined, in some instances, that the MH/SUD process was not more stringent than medical/surgical.
Additional issues that were identified as potential for non-compliance required modification in order to meet MHPAEA regulation requirements. Modifications to NQTL provisions occurred more frequently when the employer used a carve-out vendor to administer the MH/SUD benefit (i.e., MH/SUD benefit was administered by a specialty behavioral health care organization and not the same vendor as medical/surgical).
The non-compliance issues identified through the NQTL Assessment are listed below along with the outcome as reported by the vendor and/or employer:
|Potential Non-Compliance Issue||Outcome|
|Medical Management||Outpatient Precertification||Precertification required for all outpatient MH/SUD services.
Precertification is not required for all outpatient medical/surgical services.
|Precertification requirement removed for all outpatient services, but was maintained for services requiring greater oversight and supported by recognized clinically appropriate standards of care (e.g., psychiatric testing, ECT, etc.).|
|Outpatient Medical Necessity Review||All outpatient MH/SUD counseling services are authorized for up to 8-12 visits (varied by vendor). After the 8th or 12th visit, a clinical/medical necessity review is conducted.
Similar procedure not in place for outpatient medical/surgical services.
|Some vendors extended the threshold for conducting medical necessity review on outpatient MH/SUD counseling services to allow for review of cases that represent outliers (e.g., 20 visits).|
|Concurrent Review||Concurrent review conducted for all MH/SUD conditions and levels of care, including inpatient, intermediate (i.e., partial hospitalization, intensive outpatient), and outpatient.
Concurrent review was conducted only for inpatient medical/surgical cases.
|Vendor revised procedures to include only inpatient MH/SUD in concurrent review process to align with medical/surgical process.|
|Concurrent Review||Concurrent review conducted for MH/SUD cases includes a medical necessity review as well as a review for adherence to benefit provisions.
Concurrent review conducted for medical/surgical cases includes a review for adherence to benefit provisions; no medical necessity reviews.
|Concurrent review conducted for MH/SUD cases will include only a review for adherence to benefit provisions; no medical necessity reviews.|
|Retrospective Review||Retrospective review process for MH/SUD included a review for medical necessity, as well as a review for adherence to benefit provisions.
Retrospective review process for medical/surgical included a review for adherence to benefit provisions and only when no prior notification was provided.
|MH/SUD retrospective review will include a review for adherence to benefit provisions only when no prior notification was provided. No medical necessity review will be conducted.|
|Inpatient Medical Necessity Review||All inpatient MH/SUD cases require precertification and a medical necessity review is conducted during the precertification process.
For medical/surgical inpatient cases, members notify the vendor; no medical necessity review is conducted.
|Notification process implemented for MH/SUD (eliminated medical necessity review requirement). Medical necessity reviews conducted only for cases considered to be outliers based on diagnosis, high-cost and complex cases, and provider outliers.|
|Provider Network Management||Network Admission Criteria||Specific number of years of experience (e.g., 3 years of experience) required for MH/SUD network providers.
Years of experience not required for medical/surgical network providers.
|Years of experience requirement eliminated for MH/SUD network providers.|
|Network Admission Criteria||Site visits required for some MH/SUD network providers.
Site visits not required for medical network providers.
|Requirement maintained, as the requirement is essential to ensuring quality and safety of MH/SUD network providers; site visits conducted at facilities and programs that are not accredited.|
|Reimbursement Rates||MH/SUD provider reimbursement rates were determined based upon vendor's internal set of data.
Medical/surgical provider reimbursement rates were determined using an external database.
|MH/SUD provider reimbursement rates were modified to reflect a similar process and data source as medical/surgical provider reimbursement rates.|
|UCR Percentile||Percentile used to determine reimbursement rates for MH/SUD services was set at the 50th percentile.
Medical/surgical services were reimbursed at the 80th percentile.
|Reimbursement percentile rate modified to the 80th percentile for MH/SUD services.|
|Rx||Smoking Cessation Drug Requirements||Member is required to participate in a smoking disease management program in order to receive coverage for smoking cessation medication.
Similar requirement not in place for any other drug or drug class.
|Program revised to eliminate the requirement that members participate in a smoking disease management program in order to receive coverage for smoking cessation medication.|
|Smoking Cessation Drug Limits||Smoking cessation drugs limited to 12 or 24 weeks per year depending on brand.
Similar limits not imposed on other drugs or drug classes.
|Limitation removed for smoking cessation drugs.|