最终规则对精神健康平等要求进行了广泛修改

On Sept. 9, 2024, 劳工部, 卫生与公共服务部, 财政部发布了一份 final rule 加强《美高美集团4688》的要求. 根据部门, the final rule is designed to achieve MHPAEA’s purpose of ensuring individuals with private health coverage do not face greater restrictions to obtaining mental health and substance use disorder (MH/SUD) benefits than they would face for medical/surgical (M/S) benefits.

重要的是，最后的规则 增加了针对更多限制性非定量治疗限制(nqtl)的保护. For example, the final rule requires group health plans and health insurance issuers to collect and evaluate data related to the NQTLs they place on MH/SUD care and make changes if the data shows they are providing insufficient access.

最终规则通常适用于从1月11日或之后开始的计划年度的健康计划和发行方. 1, 2025; however, 某些关键要求, 如NQTL数据评价要求, 申请从1月8日或以后开始的计划年度. 1, 2026. 

MHPAEA

MHPAEA要求团体健康计划的M/S福利和MH/SUD福利相等. MHPAEA的奇偶要求适用于:

• 金融需求，例如免赔额、共付额和共同保险;
• 定量治疗的局限性, such as day or visit limits; and
• NQTLs, 哪些通常限制了福利的范围或持续时间, 例如事先授权要求, 步骤治疗要求和标准的提供者入院参与网络.

MHPAEA’s parity requirements apply to group health plans sponsored by employers with more than 50 employees. However, 因为平价医疗法案的改革, insured health plans in the small group market must also comply with federal parity requirements for MH/SUD benefits.

The Consolidated Appropriations Act of 2021 amended MHPAEA to require health plans and health insurance issuers to conduct nqtl的比较分析 与MH/SUD效益相比，用于M/S效益. 这些分析必须包含详细的, written and reasoned explanation of the specific plan terms and practices at issue and include the basis for the plan’s or issuer’s conclusion that the NQTLs comply with MHPAEA. \

Highlights

• 各部门发布了一项加强MHPAEA要求的最终规则.
• The final rule makes changes to the existing NQTL standard to prevent plans and issuers from using NQTLs to limit access to MH/SUD benefits to a greater extent than M/S benefits.
• The final rule requires health plans and issuers to collect and evaluate relevant data to assess the impact of NQTLs.
• 最终规则还为开展NQTL比较分析建立了新的最低标准. 

合规问题

The Departments have continued to receive and investigate complaints that health plans and issuers fail to comply with MHPAEA by restricting access to benefits for mental health conditions and substance use disorders in more onerous and limiting ways than those restricting access to medical or surgical care. This noncompliance is especially evident in the design and application of NQTLs that apply to MH/SUD benefits.

根据部门, 因为这些失败, people seeking coverage for MH/SUD care continue to face greater barriers when seeking these benefits than when seeking M/S  benefits. The final rule’s changes are intended to strengthen MHPAEA’s requirements and provide guidance to health plans and issuers on how to comply with the law’s requirements.

最终规则的变更

为了遵守最终规则的要求，健康计划和发行人必须:

• Define whether a condition or disorder is a MH condition or SUD in a manner that is consistent with the most current version of the International Classification of Diseases or Diagnostic and Statistical Manual of Mental Disorders;
• Offer meaningful benefits (including a core treatment) for each covered MH condition or SUD in every classification in which M/S benefits (a core treatment) are offered;
• Not use factors and evidentiary standards to design NQTLs that discriminate against MH conditions and SUDs;
• 收集和评估相关结果数据，并采取合理措施, as necessary, to address material differences in access to MH/SUD benefits as compared to M/S benefits; and
• Include specific elements in documented comparative analyses and make them  available to the Departments, 适用的国家机关, 或个人要求.

NQTL数据要求

根据最终规则, a plan or issuer may not impose any NQTL with respect to MH/SUD benefits in any classification that is more restrictive, 书面的或实际操作的, 与主要的NQTL相比，NQTL基本上适用于同一分类中的所有M/S福利. 确保NQTL在操作中不受更多限制, the final rule requires plans and issuers to collect and evaluate relevant data in a manner reasonably designed to assess the impact of the NQTL on relevant outcomes related to access to MH/SUD benefits and M/S benefits.

If the relevant data suggests that the NQTL contributes to material differences in access to MH/SUD benefits as compared to M/S benefits, 这将被视为违反MHPAEA的有力指标. 在访问方面的差异是实质性的, 基于所有相关事实和情况, the difference in the data suggests that the NQTL is likely to have a negative impact on access to MH/SUD benefits as compared to M/S benefits. 如果访问存在实质性差异, 计划或发行者必须采取合理行动, as necessary, 解决这些问题，以确保符合MHPAEA的规定.

nqtl的比较分析

The final rule establishes minimum standards for developing comparative analyses to assess whether an NQTL, 书面的和实际的, 符合MHPAEA的要求. Plans and issuers that cover both M/S benefits and MH/SUD benefits and impose NQTLs on MH/SUD benefits must perform and document a comparative analysis of the design and application of each applicable NQTL. 

最终规则要求比较分析至少包含6个内容元素:

• 对非合格清单的说明，包括确定受非合格清单约束的利益;
• Identification and definition of the factors and evidentiary standards used to design or apply the NQTL;
• 描述在NQTL的设计或应用中如何使用因素;
• 比较性和严谨性的论证，如书面的;
• 在操作上的可比性和严谨性, 包括所需的数据, 对数据的评估, explanation of any material differences in access and description of reasonable actions taken to address such differences; and
• 调查结果和结论.

在大多数情况下, issuers and third-party administrators will prepare comparative analyses for employer-sponsored health plans. 然而，最终规则要求对erisa覆盖的计划进行比较分析时也要包括一个 plan fiduciary’s certification that they have engaged in a prudent process and monitored their service providers.

生效日期

The final rule generally applies to group health plans and group health insurance coverage for plan years beginning on or after Jan. 1, 2025. However, 实施有意义福利标准的规定, 禁止歧视因素及证据标准, 需要使用结果数据, 和某些相关的比较分析要求适用于1月11日或以后开始的计划年度. 1, 2026.

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