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. Research Question #3: Health Plan and Insurer Use of Non-Quantitative Treatment Limits


What types of NQTLs are commonly used by plans and issuers for MH and/or substance abuse disorders and how do these compare to NQTLs in place for medical/surgical benefits?

According to the MHPAEA regulations, NQTLs limit the scope or duration of benefits and can include, but are not limited to, plan provisions related to:

  • Medical management.
  • Prescription drug formularies.
  • Provider admission to a network.
  • Determination of UCR amounts.
  • Step-therapy requirements.
  • 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. Assessing whether NQTLs that appear to be non-compliant are acceptable is difficult due to variations allowed by these requirements.

2010 NQTL Analysis

During Milliman's 2010 testing process of a nationally representative sample of 124 large employers' health plans, a number of NQTLs were identified that appeared to be non-consistent with MHPAEA standards. These NQTLs were identified through careful analysis of SPDs and other plan documentations and appeared to apply unequally to MH/SUD conditions when compared to medical/surgical conditions. However, no follow-up was completed with the plans in order to assess whether these variations were the result of differences in clinically appropriate standards of care. Therefore, the results of Milliman's NQTL analysis should be interpreted with caution as some of the identified NQTLs may be permissible as allowed by the IFR.

The analyses were conducted to determine changes that employers and health plans would need to take to make their 2010 plans consistent with IFR requirements for NQTLs for the 2011 plan year. As outlined in Table 28, almost 30% of plans used precertification procedures that were more stringent for MH/SUD services than for medical/surgical services.

TABLE 28. Percentage of 2010 Plans Utilizing NQTLs that Appeared to be Not Consistent With MHPAEA Standards if Continued into the 2011 Plan Year

NQTL Description Percent of Plans
MH/SUD precertification requirements were more stringent than for medical/surgical benefits. 28.2%
Medical necessity was applied to MH/SUD benefits but not to medical/surgical benefits. 8.2%
No MH/SUD benefits were provided outside the state of residence, but medical/surgical benefits were provided. 0.9%
Pre-approval was required starting with the 13th outpatient MH/SUD office visit. 1.8%
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%
Out-of-network eating disorder treatment was covered only if in-network services were unavailable; no such requirement applied to out-of-network medical/surgical benefits. 0.9%

SOURCE: Analysis of 2010 Milliman plan information.

Detailed 2010 NQTL Assessment

Aon Hewitt conducted detailed NQTL assessments in 2010 for 22 large national employers, each employing more than 1,000 workers. The analysis included the NQTL designs and practices of 17 national health vendors. The majority of these employers (72%) had 10,000 or more employees. The intensive NQTL review included a detailed assessment of how MH/SUD treatment is handled beyond plan design. The review encompassed precertification, concurrent and retrospective review, determination of reimbursement rates, and other medical management procedures to ensure that the processes in place for NQTLs are not more restrictive for MH/SUD than they are for medical/surgical treatment. Areas of potential concern identified by the NQTL testing frequently resulted in book-of-business benefit adjustments for these national vendors.

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. The following NQTL areas were assessed:

  • Precertification
    • 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
    • Process
    • Frequency of reviews
  • Discharge Planning
    • Process
    • Frequency of reviews
    • Follow-up after discharge
  • Case Management
    • Case identification process
    • Case management process
  • Retrospective Review
    • Process
    • Services included
  • UCR Determination
    • Data source
    • Frequency of updates
    • Percentile
  • Reimbursement Rates
    • Source
    • Process
  • Experimental and Investigational
    • Definition


Each MH/SUD policy and procedure was compared with corresponding medical/surgical policies and procedures. 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 whether clinically appropriate differences in care explained the variance, and whether any actions were necessary to comply with MHPAEA regulations. 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. Areas of concern, and proposed modifications are presented in Table 29.

TABLE 29. NQTLs: Areas of Concern and Modifications Made to Ensure Consistency With the MHPAEA and the IFR

  Process/Procedure     Potential Concern     Outcome  
Medical management Outpatient precertification Precertification required for all outpatient MH/SUD services. 

Precertification not required for all outpatient medical/surgical services.

Precertification requirement removed for all outpatient services, but maintained for services requiring greater oversight and supported by recognized clinically appropriate standards of care (e.g., psychiatric testing, electroconvulsive therapy [ECT], etc.)
Outpatient medical necessity review All outpatient MH/SUD counseling services authorized for 8-12 visits (varied by vendor); after 8th or 12th visit, clinical/medical necessity review 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 MH/SUD cases include 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, with a medical necessity review 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 Reimbursement rates MH/SUD provider reimbursement rates were determined based on 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.
Network admission criteria Site visits required for some MH/SUD network providers but not 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.
Prescription drugs 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.

SOURCE: Analysis of Aon Hewitt plan information and plan/vendor questionnaire.

Results from Employer Surveys. The 2010 KFF/HRET survey provides additional information on employer use of utilization management techniques in response to MHPAEA. Table 30 presents results from this question, based on employer weights. Results suggest that, overall, 4.9% of employers reported increasing their use of utilization management techniques in response to MHPAEA. Very large employers (1,000 or more employees) were significantly more likely to report an increased reliance on utilization management techniques (8.5%) than were midsized employers. Employers in the South (9.8%) were also more likely to report increasing their use of utilization management than were employers in the Northeast (2.3%) and Midwest (3.0%). Employers in the health care and retail industries were least likely to report an increased use of utilization management techniques, and self-insured employers (9%) were significantly more likely to report increased use of utilization management than their fully-insured counterparts (3.1%).

TABLE 30. Percentage of Firms that Changed Utilization Management as a Result of the MHPAEA by Firm and Worker Characteristics: Results from KFF/HRET

    Increased Utilization Management  
of MH Benefits
All Firms 4.9%
Firm Size
50-199 employees 4.6%
200-999 employees 4.6%
1,000 or more employees 8.5%*
Plan Funding
Underwritten by insurer 3.1%*
Self-insured 9.0%

SOURCE: Estimates are from author analysis of data from 2010 Henry J. Kaiser Family Foundation/Health Research and Educational Trust 2010 Employer Health Benefits Survey public use file.

* Estimate is statistically different from reference group (P < 0.05).

This issue is also addressed in the 2010 Mercer Survey, which asked responding employers to describe planned or implemented changes made to their health benefits in response to the MHPAEA. Of the 1,433 participating employers, approximately 8% of employers reported adding or adjusting their use of utilization management techniques in response to MHPAEA.

View full report


"mhpaeAct_0.pdf" (pdf, 1.34Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®