1. Let’s Go Back to the Basics
MHPAEA 101 – HEALTH TRACK
Jo-Anne Fameree, Risk & Regulatory Consulting
Irvin “Sam” Muszynski, American Psychiatric Association
Katie Dzurec, Pennsylvania Insurance Department
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2. Agenda Overview of MHPAEA QTL and Financial Requirement analysis
Subtitle 1
Overview of MHPAEA
Timeline
Regulatory Provisions
Key Terms
QTL and Financial Requirement analysis
NQTL analysis
Resources for Regulators
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3. Legislative & Regulatory Timeline
Overview of MHPAEA
Legislative & Regulatory Timeline
Oct 3, MHPAEA passed, amending PHS Act, ERISA, & IRC
Feb 2, 2010 Interim Final Rule published
Nov 13, 2013 Final Rule published
Jul 1, 2014
Final Rule effective
Oct 3, 2009
MHPAEA effective
July 1, 2010
IFR effective
2008
2009
2010
2013
2014
2016
Mar 23, Affordable Care Act
Sept 23, 2010 ACA EHB reforms effective
Dec 13, 2016: 21st Century Cures
Support for Patients and Communities Act: Oct. 24, 2018
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4. Overview of MHPAEA The rules are sequential and interrelated
Essentials
The rules are sequential and interrelated
Identify MH/SUD disorder
Identify MH/SUD benefit
Identify med/surg benefit
Classification of MH/SUD and med/surg benefits
Financial requirements & QTL
NQTL – medical necessity, information disclosure
Vendor coordination
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5. Regulatory Provisions
Overview of MHPAEA
Regulatory Provisions
If a Company provides both med/surg benefits and MH/SUD benefits, then the Company must comply with parity requirements
may not apply any financial requirement or treatment limitation MH/SUD benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all med/surg benefits in the same classification
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6. Overview of MHPAEA Financial Requirements:
Key Terms
Financial Requirements:
Type – deductibles, copayments, coinsurance, or out-of-pocket maximums
Level – the dollar amount or number of visits/sessions
Treatment limitations – limits on benefits based on scope or duration of treatment (e.g., frequency, number of visits, days of coverage)
Quantitative (QTL) – determine whether or to what extent benefits are provided based on accumulated amounts, such as annual or lifetime day or visit limits. Expressed numerically
Nonquantitative (NQTL) – limit the scope or duration of benefits for treatment under a plan or coverage (e.g., prior authorization, formulary design, network)
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7. Overview of MHPAEA
Key Terms
MH/SUD Disorder – consistent with generally recognized standards of current medical practice
MH/SUD Benefit – services primarily provided in conjunction with treatment for MH/SUD conditions
Classifications
Subclassifications
Inpatient, in-network
Inpatient, out-of-network
Outpatient, in-network
Outpatient, out-of-network
Emergency care
Prescription drugs
Office/all other for outpatient
Drug tiering
Provider network tiering
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8. For each classification…
QTL and Financial Requirement Analysis
For each classification…
substantially all and predominant level are based on ratio of expected claims dollar amounts for the covered service to the amounts for ALL covered services
Does the limit apply to substantially all (2/3) of Med/Surg?
What is the predominant level (50%)?
MH/SUD levels must be equal to or less than the predominant level
STOP! Cannot be applied to MH/SUD
YES NO
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9. Outpatient, In-Network classification
Copay - $244,728,384.78/$717,781,326.50
Coinsurance –
$0/$717,781,326.50
Deductible –
$206,965,525.50/$717,781,326.50
None of the cost-sharing types meets the substantially all requirement, so no financial requirements can be applied to the MH/SUD outpatient, In-Network classification
This template is for illustration of larger charts, images, and intricate visuals that require more space.

10. Outpatient, In-Network, Office sub-classification
Classification: OPTIONAL SUBCLASSIFICATION- OUTPATIENT, IN-NETWORK, OFFICE
COLUMN 1
COLUMN 2
Service Categories within OUTPATIENT, IN-NETWORK, OFFICE
EXPECTED CLAIM DOLLAR AMOUNT
COPAY APPLICATION
INSTRUCTIONS: List all MEDICAL/SURGICAL service categories within the OUTPATIENT, IN-NETWORK, OFFICE classification below.
INSTRUCTIONS: List Claim Expected Allowed Dollar Amounts (Annual) for each service category listed.
INSTRUCTIONS: Is a copay applied to this service category? If yes, list the copay Dollar Amount Applied to the Service Category. If no, put a "N" for every Service Category where there is no copay application.
ADULT PREVENTIVE/HEALTH SCREENING EXAMINATION
$ ,634,826.65 N
PEDIATRIC IMMUNIZATIONS
$ ,103,247.38
PEDIATRIC PREVENTIVE/HEALTH SCREENING EXAMINATION
$ ,694,170.52
PREVENTIVE
$ ,853,595.57
SCREENING GYNECOLOGICAL EXAM
$ ,633.10
PHYSICAL, SPEECH, AND OCCUPATIONAL THERAPY
$ ,816,315.51 30
PODIATRIC CARE
$ ,967,757.05
PROVIDER OFFICE VISIT (FOR ILLNESS OR INJURY)
$ ,277,517.51 20
SPECIALIST OFFICE VISIT, INCLUDING OB-GYN
$ ,989,926.12 40
THERAPEUTIC MANIPULATION
$ ,817,696.12
URGENT CARE FACILITY
$ ,859,172.47
AGGREGATE TOTAL OF MEDICAL AND SURGICAL BENEFITS EXPECTED CLAIM DOLLAR AMOUNT WITHIN OUTPATIENT, IN-NETWORK, OFFICE CLASSIFICATION
$304,537,858.00
For every row in COLUMN 2 with an amount listed, ADD the expected claim dollar amounts (COLUMN 1) for the service category listed within that row.
AGGREGATE TOTALS
$ ,728,384.78
DIVIDE the AGGREGATE TOTAL of all rows with COPAY listed (COLUMN 2), indicating copay is applied, by the AGGREGATE TOTAL of COLUMN 1.
If the amount listed within this row is not greater than or equal to 2/3, or 66.67%, the QTL cannot be applied for this plan design.
80.36%
Outpatient,
In-Network, Office
sub-classification
Copay meets substantially all for TYPE, so we go to predominant level to see what the maximum amount can be…
LEVELS OF COPAYS, LOWEST TO HIGHEST
TOTAL EXPECTED CLAIM DOLLARS APPLIED AT THIS COPAY LEVEL
PERCENT (%) OF CLASSIFICATION APPLIED AT THIS LEVEL [LEVEL $ AMOUNT DIVIDED BY TOTAL A $]
START HERE, MOVE DOWNWARD ONE LEVEL UNTIL AGGREGATE TOTAL OF LEVELS REACH OVER 50.01%; STOP. THAT IS THE PREDOMINANT LEVEL, AND THE HIGHEST LEVEL THAT CAN BE APPLIED TO MH/SUD BENEFITS.
$20.00
$51,277,518.00
20.95%
$30.00
$58,460,941.00
23.89%
44.84%
$40.00
$134,989,926.00
55.16%
100.00%
TOTAL A:
$ ,728,385.00

11. NQTL analysis NQTLs applied to MH/SUD must be Comparable to, and
Subtitle 1
NQTLs applied to MH/SUD must be
Comparable to, and
Applied no more stringently
Than those applied to med/surg
NQTL analysis must be compliant BOTH as written and in operation
Mary: Federal examples, comments.

12. NQTL analysis Walk through provisions Provide examples Subtitle 1
Mary: Federal examples, comments.

13. MHPAEA Resources for Regulators
Subtitle 1
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