URAC Parity Standards

URAC's new standards – Version 7 – for accreditation of health plans - have incorporated the federal parity law (MHPAEA) and the regulations (IFR) that govern the statute. The parity related requirements are addressed in multiple areas of the standards which are outlined below. In each section below we have excerpted key language related to parity. In the attachment, the full standards are included with all relevant language about the mental health and substance use disorder parity law highlighted.

The inclusion of the federal parity law and its regulation in these standards provides an additional level of oversight on MHPAEA compliance for health plans. There are several features that we believe are critical in achieving full compliance with parity, as follows:

Summary of Key Issues in URAC Parity Standards

  1. A plan must conduct a detailed internal audit and analysis of each medical management (nonquantitative) intervention applied to behavioral health treatments to assure that these interventions are “comparable to and no more stringent than” those applied to medical treatments. These audits must be overseen by the compliance officer and will be reviewed by URAC.
  2. A plan must assure that any mental health or substance use disorder (MH/SUD) services contractor (e.g., a managed behavioral health organization) is in full compliance with MHPAEA.
  3. A plan is required to document that they have disclosed key aspects of the behavioral health benefit to consumers and employers, such as: how compliance with parity is achieved and any restrictions or exclusion on the behavioral health benefit.
  4. The standards define utilization management (UM) protocols as “any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health or substance use disorder benefits” not just medical necessity criteria.
  5. In the Network standards, a plan must document that it has provided parity between medical and behavioral health treatment services in certain levels and types of care, (see the IFR for the 6 classifications of benefits), such as emergency care, pharmacy and inpatient and outpatient treatment.
  6. URAC will review and audit appeals about health plan decisions and a consumer can make a complaint directly to URAC regarding the actions (or lack thereof) surrounding compliance with parity. See below for directions.


URAC Standards Requiring MHPAEA Compliance (Emphasis supplied throughout)

  • Core standards
    • Core 4 - Regulatory Compliance
  • Network Management
  • P-NM 4 - Out of Network and Emergency Services
  • “Organizations must ensure that all out of network mental health and/or substance use disorder (MH/SUD) benefits are complaint with the Mental Health Parity and Addiction Equity Act (MHPAEA).
  • An organization (i.e., health plan) that provides MH/SUD benefits any classification of

benefits must provide them in every classification in which medical/surgical benefits are

provided, including out-of-network classifications for emergency services.

  • Please reference the standards found in the Compliance Program and Mental Health

Parity sections of this accreditation for more information on parity, including mental health parity, as it would be addressed as part of a compliance program.”

  • Member Relations
    • P-MR 2 - Consumer and Employer Purchaser Information Disclosure

“ (4)

(m) Descriptions of the processes that the organization uses to ensure compliance with regulatory health care parity requirements, including regulations pertaining to mental health and/or substance usage disorders (MHPAEA) if applicable

Interpretive Information/Commentary

The information provided under P-MR 2(k) should provide enough information to allow a consumer to understand any benefits provisions that affect a specific health condition. For example, a prospective enrollee may wish to know whether the benefits package includes any special provisions that address coverage and exclusions for diabetes”

”P-MR 2(m) refers to care parity including mental health parity”

Points to Remember

“MR 2(m): Addresses health care parity including mental health parity. Plan coverage is key information to share with consumers and employer purchasers”

“(m) Descriptions of the processes that the organization uses to ensure compliance with regulatory health care parity requirements, including regulations pertaining to mental health and/or substance usage disorders (MHPAEA) if applicable”

Compliance Program

P-CP 1 - Compliance Program: Internal Controls

“To effectively monitor adherence to applicable statutes and regulations, the organization implements internal controls including:

(No Weight)

(a) Designating a compliance officer;

(4)

(b) Pursuant to the organization's policy, periodic review and update of the compliance program in the organization's training and education;

(2)

(c) Pursuant to the organization's policy, periodic internal monitoring and auditing;

(2)

(d)

(No Weight)

(i) Periodic review and analysis to determine if there are any changes in its benefits, policies and procedures, and utilization management protocols that

impact compliance; and

(2)

(ii) Communication to delegated contractors regarding changes impacting compliance, including parity of health care services such as mental health and/or substance use disorder parity (MHPAEI), as applicable;

(e) Performance of a thorough review of state and federal laws and regulations related to:

(ii) Parity of health care services such as mental health and/or substance use disorder parity, including MHPAEA, as applicable;”

  • Mental Health Parity
    • P-MHP 1 - Analysis of Compliance with Mental Health Parity Law

“For each health benefit plan product that provides mental health and/or substance use disorder (MH/SUD) services that is included in its application for this accreditation, the organization will provide written documentation of one of the following:

(No Weight)

(a) An affirmative declaration, signed by a principal of the organization, indicating that the identified product is in "exempt status" with regards to the applicable federal and/or state law or regulation and any binding regulatory or sub-regulatory guidance related thereto, including the statutory/regulatory basis for the exempt status; or

(4)

(b) If not exempt, a detailed analysis of the identified product documenting its compliance with the applicable federal and/or state law or regulation and any binding regulatory or sub-regulatory guidance related thereto, demonstrating that for the MD/SUD services provided, including applicable pharmacy benefits, the organization does not have more restrictive:

(No Weight)

(i) Financial requirements;

(4)

(ii)Quantitative treatment limitations; and

(4)

(iii) Nonquantitative treatment limitations.”

(4)

Interpretive Information/Commentary

  • The requirement for a detailed, documented analysis of an organization’s compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) is an essential first step towards complying with this Act. URAC will not pass judgment as to whether the conclusions are valid; however, a reasoned analysis of the applicable health benefit plan is necessary to meet the intent of the standard.
  • As part of that reasoned analysis, if there is medical or scientific evidence and/or clinical practice guidelines (often collectively referred to as “standard of care”) permitting a difference between mental health/substance use disorder treatment or service benefits and those for medical/surgical, then the organization needs to include that evidence/standard of care as part of its reasoned analysis. A declaration that there is medical or scientific evidence to that effect will not suffice.
  • Pharmacy benefits are a benefit classification under the interim final rules for MHPAEA. As such, they must be compliant with the parity rules. Formulary structure and the management thereof should also be in compliance with the Interim Final Rules (IFR) rules respecting financial, quantitative and non-quantitative treatment limitations applicable to the pharmacy benefit. The validation thereof is documentation that a compliance analysis was performed with a clear rationale supporting the conclusions.”

Points to Remember

  • If an organization provides MH/SUD services through other than mental health providers, such as a PCP, then MHPAEA applies, even if MH/SUD benefits are not provided as part of the health benefit plan.”
    • P-MHP 2 - UM Protocols Applied to MH/SUD Benefits

For all of the utilization management protocols applied to mental health and/or substance use disorder (MH/SUD) benefits, theorganization will provide a detailed analysis demonstrating that these utilization management protocols do not have more restrictive nonquantitative treatment limitations.

(4)”

Interpretive Information/Commentary

  • “The requirement for a detailed, documented analysis of an organization’s compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) is an essential first step towards complying with this Act. URAC will not pass judgment as to whether the conclusions are valid; however, a reasoned analysis of the utilization management protocols is necessary to meet the intent of the standard.
  • UM protocols are by definition non-quantitative treatment limitations (“NQTLs”); therefore, UM protocols must be comparable to, and applied no more stringently than, those used for medical/surgical benefits. Since there are no “bright line” rules here, the organization must present its analysis supporting its conclusions one way or another. As previously mentioned, a URAC reviewer cannot opine on the validity, but can review to see that a compliance analysis was done; therefore, a one-sentence declaration that the organization is in compliance with the MHPAEA is not acceptable as evidence.
  • Note that any NQTL, such as a UM protocol, does not have to meet the “…must be comparable to, and applied no more stringently than, those used for medical/surgical benefits…” test if there is recognized, clinically appropriate medical or scientific evidence and/or clinical practice guidelines (sometimes collectively called “standard of care”) that permits a “difference.”
  • If evidence or standard of care permits a difference between the mental health and/or substance use disorder UM protocols and processes as compared to medical/surgical ones, then they must be cited in the documentation in support of drawing that conclusion.”

Scope of Standards

  • This standard applies to all UM protocols used for health benefit plans included within the scope of the organization’s application for accreditation.
  • The term “protocol” includes “…any processes, strategies, evidentiary standards, or other factors used in applying the non-quantitative treatment limitation to mental health or substance use disorder benefits…” [Federal Register, Vol. 75, No. 21, page 5416, 45 CFR Part 146, IFR under the HCPAEA]”

Evidence for Meeting the Standard - Desktop Review Materials

  • “Copy of the report or executive summary of parity analysis of HUM protocols for MH/SUD benefits.”

Evidence for Meeting the Standard - Onsite Review Materials and Activities

  • “Interview with Compliance Officer.
  • Interview with Senior Clinical Staff Person.”
    • P-MHP 3 - MH/SUD Parity Addressed in Contractor Written Agreements

“The organization enters into written agreements with contractors providing mental health and/or substance use disorder (MH/SUD) health care services that:

(No Weight)

(a) Meet the requirements set forth in standards P-NM 8-10; and

(4)

(b) Specify that the contractor shall comply with, and maintain parity between the MH/SUD benefits it administers and the organization'smedical/surgical benefits pursuant to the applicable federal and/or state law or regulation and any binding regulatory or subregulatory guidance related thereto.

(4)”

Interpretive Information/Commentary

  • “Compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and any binding regulatory or sub-regulatory guidance related thereto must be addressed in contract language.”

Points to Remember

  • “This standard is implemented on a going-forward basis, such that current compliance program written policies and/or documented procedures must be in effect at the time an organization submits its application for initial accreditation or reaccreditation under this standard. For every contract executed after that submittal date, URAC will examine client-specific documentation showing that mental health parity is addressed in the contracts between the organization and its contractors for mental health and substance use disorder health care services.
  • See also standard P-CP 1(d), where it addresses communication to delegated contractors regarding changes impacting compliance.”

Scope of Standards

  • “This standard applies to the contracts between the organization and its contractors for mental health and substance use disorder health care services.
  • This standard includes delegation of pharmacy benefit management (PBM) services.”

Evidence for Meeting the Standard - Desktop Review Materials

  • “Sample or template of agreement with contractors providing mental health and/or substance use disorder (MH/SUD) health care services.”

Evidence for Meeting the Standard - Onsite Review Materials and Activities

  • “Review of agreements with contractors providing mental health and/or substance use disorder (MH/SUD) health care services.
  • Interview with Compliance Officer.”

Health Utilization Review Management

P-HUM-1 – Review Criteria Requirements

Interpretive Information/Commentary

  • “When the Mental Health Parity and Addiction Equity Act (MHPAEA) is applicable, “…the criteria for medical necessity determinations made under a group health plan with respect to mental health or substance use disorder benefits (or health insurance coverage offered in connection with the plan with respect to such benefits) must be made available in accordance with regulations by the plan administrator (or health insurance issuer offering such coverage) to any current or potential participant, beneficiary, or contracting provider upon request (“medical necessity disclosure”) [Federal Register, Vol. 75, No. 21, page 5428, 45 CFR Part 146, Interim Final Rule (IFR) under the MHPAEA] For health plans and entities that provide utilization management services for them, complying with this regulation is required under standard Core 4 – Regulatory Compliance, when the MHPAEA is applicable.”

P-HUM 37 - Written Notice of Upheld Non-Certification

Interpretive Information/Commentary

  • When the Mental Health Parity and Addiction Equity Act (MHPAEA) is applicable, the “…MHPAEA also requires the reason for any denial under a group health plan (or health insurance coverage) of reimbursement or payment for services with respect to mental health or substance use disorder benefits in the case of any participant or beneficiary must be made available upon request or as otherwise required by the plan administrator (or health insurance issuer offering such coverage) to the participant or beneficiary in accordance with regulations (“claims denial notice”) [Federal Register, Vol. 75, No. 21, page 5428, 45 CFR Part 146, Interim Final Rule (IFR) under the MHPAEA] For health plans and entities that provide utilization management services for them, complying with this regulation is required under standard Core 4 – Regulatory Compliance, when the MHPAEA is applicable.”

Filing a Complaint with URAC

For consumers to submit a complaint: On the URAC Web site (www.urac.org), click on the "Consumer" tab/portal, select "Consumer Resource Center" (left side of screen) and then click on the first bullet "A Step-by-Step Guide on How to File a Complaint." Keep in mind that an organization has to be accredited and accredited for the area that is covered by the complaint in order for URAC to take action after investigating the complaint. All complaints receive a response.”