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The ‘No More Restrictive’ Requirement for NQTLs Under the Proposed MHPAEA Regulations

We previously reported on proposed regulations under the Mental Health Parity and Addiction Equity Act (MHPAEA). If adopted in final form, these regulations would vastly complicate compliance by group health plans and health insurance issuers with an already challenging set of mental health parity rules.

The proposed regulations deal principally with non-quantitative treatment limitations (NQTLs), i.e., non-numeric benefit coverage limits that must be no more restrictive for mental health and substance use disorder (MH/SUD) benefits than for medical surgical (M/S) benefits. Examples of NQTLs include prior authorization requirements, concurrent review, standards for provider admission, Rx formulary design, and fail-first policies or step therapy protocols.

The proposed regulations set out new requirements on NQTLs that include a three-part test consisting of a “no more restrictive” requirement, a “design and application” requirement and a “data evaluation requirement.” There is also a new meaningful benefit requirement, under which plans and issuers must provide meaningful benefits for MH/SUD treatment where the plan also provides a corresponding M/S benefit. With perhaps the exception of the “design and application” requirement, each of these requirements represents a major new compliance obligation on the part of plans and issuers.

This blog post focuses on the “no more restrictive” requirement. Future posts will examine the other requirements.

MHPAEA regulates aggregate lifetime and annual dollar limits, financial requirements, and treatment limitations. (The Affordable Care Act bars lifetime and annual dollar limits on essential health benefits (EHBs). Under MHPAEA, plans and issuers may not be able to impose lifetime and annual dollar limits on MH/SUD benefits that are not EHBs.) Treatment limitations are subdivided into quantitative treatment limitations (QTLs) (e.g., number of days or visits covered) and NQTLs.

The 2013 final MHPAEA regulations apply numerical standards testing to financial requirements and QTLs. These final regulations also adopted six classifications of benefits for this purpose: inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-of-network; emergency care; and prescription drugs. To comply, a financial requirement or QTL imposed on an MH/SUD benefit must be no more restrictive than the predominant financial requirement or QTL that applies to substantially all M/S benefits in a classification. For this purpose:

  • Substantially all” means that the financial limitation or QTL applies to at least two-thirds of all M/S benefits in the classification; and
  • “Predominant” means the level of financial requirement or QTL that applies to more than one-half of the M/S benefits in the relevant classification.

The 2013 final regulations largely rely on a subjective analysis of the processes, strategies, evidentiary standards, and other factors used in the application of NQTLs. The proposed regulations retain this subjective standard and layer on a quantitative “no more restrictive” requirement. As proposed, NQTLs would be subject to numerical standards testing similar to the current law testing that applies to financial requirements and NQTLs. While the “substantially all” prong would not change, some minor modifications would be made to the “predominant” prong. Under the proposed regulations, when testing NQTLs, the term “predominant” [...]

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There’s a Party Going on Right Here! Roth Catch-Up Change Delayed Two Extra Years!

Yahoo! Let’s celebrate—the IRS gave us more time!

On August 25, 2023, the Internal Revenue Service announced an administrative transition period that effectively delays the deadline for adding Roth catch-up contributions under the SECURE 2.0 Act until at least 2026. Specifically, the announcement provides that, until 2026, catch-up contributions will satisfy the requirements under SECURE 2.0, even if the contributions made for high-wage earners (i.e., those making more than $145,000 from their employer in the prior year) are not designated as Roth contributions.

Read more here.

Tenth Circuit Reaffirms Preemption of State Pharmacy Network Regulations

The US Court of Appeals for the Tenth Circuit recently held in Pharmaceutical Care Management Association v. Mulready (PCMA) that the Employee Retirement Income Security Act (ERISA) and Medicare Part D preempted several provisions of Oklahoma law regulating pharmacy benefit managers and pharmacy networks. Left unchallenged, these provisions threaten the ability of employers and Medicare Advantage organizations to design uniform nationwide health plans. The Tenth Circuit’s decision in favor of PCMA overturned a lower court decision that caused great concern about the ability of states to indirectly dictate the design of plans governed by ERISA and Medicare Part D.

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Forfeitures: Changing the Rules of the Game for Retirement Plans

The US Department of the Treasury and the Internal Revenue Service recently issued proposed regulations on the use of forfeitures by tax-qualified retirement plans. The proposed changes provide welcome clarity for plan sponsors but may require revisions to plan administration and legal plan documents.

Read more here.

Better Than a Snow Day: The PBGC Provides One-Time Section 4010 Reporting Waiver

In an acknowledgment of uncommon market conditions and their corresponding effect on defined benefit pension plan funding, the Pension Benefit Guaranty Corporation (the PBGC) provided a welcome one-time waiver for some underfunded pension plans under Section 4010 of the Employee Retirement Income Security Act (ERISA). However, to qualify for the waiver, pension plan sponsors still need to timely notify the PBGC.

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Just Catching Up? For SECURE 2.0’s Catch-Up Contributions, Age Is More Than Just a Number

Nearly all employers offer eligible participants the opportunity to make additional catch-up contributions to their retirement plans. However, beginning in 2025, the SECURE 2.0 Act makes so-called “super-catch-up contributions” available to certain employees. Adding this new feature will require employers and their service providers to develop new processes to monitor various ages and limits and to audit that information to ensure it is properly applied.

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IRS Opines on the Tax Treatment of Employer-Funded, Insured, Fixed-Indemnity Wellness Policies

In light of recent Internal Revenue Service (IRS) guidance, employers should carefully examine any supplemental health plan, program or arrangement (which may or may not claim to leverage fixed indemnity insurance) that promises substantial payroll tax savings. In a legal advice memorandum, the IRS’s Office of Chief Counsel addressed and rejected the claimed tax treatment and purported advantages of certain “wellness indemnity” payments under an employer-funded hospital indemnity or other fixed indemnity insurance policy. The arrangement described in the memo is similar to other so-called “double dipping” arrangements that the IRS has previously rejected.

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Treasury, DOL and HHS Issue Landmark Mental Health Parity Proposed Rule

The US Departments of the Treasury, Labor, and Health and Human Services (the Departments) recently issued much-anticipated proposed regulations under the Mental Health Parity and Addiction Equity Act (MHPAEA) to better ensure that health plans allow access to mental health or substance use disorder benefits as easily as medical or surgical benefits. The proposed regulations reiterate the Departments’ focus on mental health parity and underscore the importance of compliance for health plan sponsors. They also come after many plans have been subject to audit by the Departments which focused heavily on MHPAEA compliance, leaving plan sponsors frustrated at the lack of guidance and inconsistent application of MHPAEA.

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Nevada and Connecticut Pass Consumer Health Data Laws

Following in the footsteps of Washington State’s My Health My Data Act, the governors of Nevada and Connecticut recently approved Nevada SB 370 and Connecticut SB 3. These bills impose a number of new requirements on the processing of consumer health data. Nevada SB 370 will go into effect on March 31, 2024, while the consumer health data-related provisions of Connecticut SB 3 that amend the Connecticut Data Privacy Act will take effect on July 1, 2023.

Read more here.




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