Who is required to comply?

• Generally, health plans and health insurers offering group health insurance coverage.

What is required? 

• The Consolidated Appropriations Act of 2021 (CAA) requires a comprehensive comparative analysis to be done to prove that the financial requirements and treatment limitations on mental health or substance use disorder (MH/SUD) benefits provided under a group health plan are no more restrictive than those on medical or surgical (medical/surgical) benefits.
• Treatment limitations may be quantitative treatment limitations (QTLs), which are numerical (such as visit limits or copayments), or non-quantitative (NQTLs), which are nonnumerical limits on the scope or duration of benefits for treatment (such as preauthorization requirements or standards for provider admission to participate in a network).

Who is responsible for the analyses?  

• Fully insured plans may primarily be able to rely on their carriers.
• Self-insured plans the plan sponsor is ultimately responsible for meeting the reporting requirements but likely will need to work with their TPA/PBM to obtain the underlying data.

When is the analysis required to be provided? 

• The comparative analysis, and certain other information, must be made available upon request to applicable agencies beginning Feb. 10, 2021.

How should plan sponsors (employers) prepare?

• Fully insured
  • Ask your carrier if they are prepared to show the ability to meet the NQTL comparative analysis reporting requirement.
  • Check to see if they will provide you with a report so you have it available if requested.
• Self-insured
  • Check with your TPA & PBM to see if they can help with the analyses.
  • If they are not offering this service, ask if they will provide you with a list of the NQTLs by type of MH/SUD and medical/surgical benefits, which is the starting point for comparative analysis.
  • The DOL has provided a self-compliance tool and made it clear that the analysis must include a “robust discussion” of nine specific elements and include supporting documentation.
  • Although the DOL believes the use of the tool will provide a plan sponsor the ability to submit a comparative analysis, it’s not for the faint of heart.
  • It may be best to work with legal counsel or another qualified vendor (e.g., Milliman) to get a report.

Why does it matter?  

• If the report is requested by federal regulators, and adequate testing information is not received. The plan sponsor will have 45 days to provide another analysis. After which, there can be financial penalties for noncompliance and the plan sponsor must notify all plan participants of their non-compliant status.
• Plan participants may also request to see an NQTL comparative analysis and DOL penalties may apply for violations to comply.

If you have questions about the above, or need help with another employee benefits administration question, please contact us! We would love to hear from you!

The Compliance Rundown is not a law firm and cannot dispense legal advice. Anything in this post or on this website is not and should not be construed as legal advice. If you need legal advice, please contact your legal counsel.