Mental Health Parity & Addiction Equity Act (MHPAEA)

Evaluate compliance with Mental Health Parity and Addiction Equity Act covering insurance coverage equity, treatment limitations, and disclosure requirements

HealthcareInsuranceMental-health25 minutes18 questions

1. Financial Requirements

Are deductibles for mental health/substance use (MH/SU) no more restrictive than medical/surgical?*

MHPAEA: MH/SU deductibles cannot be higher than predominant med/surg deductibles

Are copayments and coinsurance for MH/SU equivalent to medical/surgical?*

Same copay/coinsurance structure for inpatient, outpatient, emergency, prescription drugs

Are out-of-pocket maximums equal for MH/SU and medical/surgical benefits?*

Single OOP max applies to all benefits; cannot have separate caps for MH/SU

2. Treatment Limitations

Are day/visit limits for MH/SU no more restrictive than medical/surgical?*

No annual or lifetime visit limits for MH/SU unless similar limits apply to med/surg (generally prohibited)

Are there no lifetime or annual dollar limits on MH/SU benefits?*

ACA/MHPAEA: Lifetime and annual dollar limits prohibited for all essential health benefits

Is residential treatment covered at parity with medical/surgical?*

Residential MH/SU treatment covered if plan covers med/surg skilled nursing or rehab

3. Non-Quantitative Treatment Limitations

Are prior authorization requirements for MH/SU comparable to medical/surgical?*

NQTL: Prior auth processes, criteria, frequency applied no more stringently to MH/SU

Are medical necessity criteria for MH/SU evidence-based and comparable?*

Same standard of evidence for MH/SU and med/surg; no arbitrary exclusions

Is step therapy applied equivalently to MH/SU and medical/surgical?*

Fail-first requirements no more restrictive for MH/SU medications

4. Disclosure & Transparency

Are medical necessity criteria disclosed to participants on request?*

MHPAEA requires disclosure of MH/SU medical necessity criteria within 30 days

Are reasons for adverse benefit determinations provided in writing?*

Denial letters must explain specific medical necessity criteria, appeal rights

Are appeals processes the same for MH/SU and medical/surgical denials?*

Internal and external review timelines, standards equal for all benefits

5. Network Adequacy

Is the MH/SU provider network comparable in size to medical/surgical?*

Sufficient number and types of MH/SU providers (psychiatrists, therapists, facilities)

Are out-of-network reimbursement rates for MH/SU equitable?*

OON rates for MH/SU providers no less favorable than med/surg OON rates

Are wait times for MH/SU appointments tracked and comparable to medical/surgical?*

Monitor average days to appointment, address access barriers

6. Compliance Documentation

Is a parity analysis documented for all NQTLs?*

Written comparative analysis of processes, strategies, evidentiary standards for NQTLs

Are parity complaints logged and investigated?*

Process to receive and respond to parity complaints from members, providers, regulators

Is parity compliance reviewed at least annually?*

Annual review of benefit design, claims data, network adequacy, NQTL application

Please answer all required questions to see your results