mental health parity legal requirements for employer...

Mental Health Parity Legal Requirements for

Employer Health Plans: Increased Risks

to Plan SponsorsMHPAEA Compliance, Enforcement, Litigation and Best Practices for Health Plan Audits

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TUESDAY, JULY 17, 2018

Presenting a live 90-minute webinar with interactive Q&A

Ryan C. Temme, Attorney, Groom Law Group, Washington, D.C.

Christopher W. Welsch, Attorney, Winston & Strawn, Chicago

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JUL Y 17, 20 18

Mental Health Parity Legal Requirements for Employer Health

Plans: Increased Risks to Plan Sponsors

Ryan TemmeGroom Law Group

Washington, [email protected]

Chris WelschWinston & Strawn LLP

Chicago, [email protected]

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Overview

I. Overview of MHPAEA requirements and exceptions for plans providing MH/SUD benefits

II. DOL, HHS and Treasury guidance for MHPAEA and ERISA compliance

III. DOL parity compliance enforcement and handling health plan audits

IV. Class action lawsuits and preventative methods to avoid them

V. Best practices for conducting internal audits of group health plans for MHPAEA compliance

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T h e M e n t a l H e a l t h P a r i t y A c t o f 1 9 9 6 p r o h i b i t s g r o u p h e a l t h p l a n s f r o m p l a c i n g l i f e t i m e o r a n n u a l l i m i t s o n m e n t a l h e a l t h b e n e f i t s t h a t d i d n o t a p p l y t o s u b s t a n t i a l l y a l l m e d i c a l / s u r g i c a l b e n e f i t s .

T h e P a u l W e l l s t o n e a n d P e t e D o m e n i c i M e n t a l H e a l t h P a r i t y a n d A d d i c t i o n E q u i t y A c t o f 2 0 0 8 ( t h e “ A c t ” ) p a s s e d i n 2 0 0 8 a n d w a s i n t e n d e d t o p r o v i d e p a r i t y f o r t r e a t m e n t l i m i t s a n d f i n a n c i a l r e q u i r e m e n t s .

T h e A c t w a s e f f e c t i v e J a n u a r y 1 , 2 0 1 0 f o r c a l e n d a r y e a r p l a n s ( p r i o r t o t h e i s s u a n c e o f r e g u l a t i o n s ) .

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I. Overview of MHPAEA requirements and exceptions for plans providing MH/SUD benefits

Background: MHPAEA Regulations

Interim Final Rule (IFR) was issued by IRS, CMS and DOL on February 2, 2010.

The IFR was applicable for the first plan year beginning on or after July 1, 2010.

IFR established parity standards for financial requirements, quantitative treatment limits and non-quantitative treatment limits on a classification-by-classification basis.

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Interim Final Rule

The IFR required parity for both quantitative and non-quantitative treatment limits (“NQTLs”).

NQTLs are any limitation on the scope or duration of coverage that cannot be measured numerically.

The IFR also required that parity be analyzed on a classification basis, and described six classifications that plans must use. Inpatient, in-network; Inpatient, out-of-network; Outpatient, in-network;

Outpatient, out-of-network; Emergency care; and Prescription drug

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Final Rule

The Final Rule was issued by IRS, CMS and DOL on November 13, 2013

The Final Rule was applicable for the first plan year beginning on or after July 1, 2014

The Final Rule permitted sub-classifications, established requirements for intermediate levels of care and added examples of non-quantitative treatment limits

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Classifications and Coverage Units

Specific classifications required by the rule are: Inpatient, in-network

Sub-classification for multiple network tiers;

Inpatient, out-of-network

Outpatient, in-network

Sub-classification for office visits;

Sub-classification for multiple network tiers;

Outpatient, out-of-network

Sub-classification for office visits;

Emergency care

Prescription drug

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Financial Requirements

The Act requires that financial requirements that apply to mental health or substance use disorder benefits be “no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan.” Financial requirements include deductibles, copayments, coinsurance and out-of-

pocket maximums

A plan may not (without passing the parity tests) treat all mental health/substance abuse disorder providers as specialists and automatically apply a higher copayment than for primary care physicians for medical/surgical

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Financial Requirements – Add’l Guidance

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MHPAEA Final Rule “[A]ny reasonable method may be used to determine the dollar amount expected to

be paid under a plan for medical/surgical benefits subject to a financial requirement or quantitative treatment limitation.” 45 CFR 146.136(c)(i)(E).

Data must be reasonable and must result in reasonable projections.

FAQs in April and October provided additional guidance on the flexibility that issuers retained to utilize data that is not specific to the plan in question.

Data Requirements Under FAQs

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Step 1: Large group/self-funded: Is group health plan level data sufficient? Small group/individual: Is plan level data (combination of benefit design, cost-sharing, network type, and service area) sufficient? If yes, then that data must be used. If no, then go to Step 2.

Step 2: Large group/self-funded: Is product level data (note: not a defined term) sufficient? Small group/individual: Is product (combination of benefit design, network type, and service area) level data sufficient? If yes, then that must be used. If not, then go to Step 3.

Step 3: All markets: Use data from other similarly structured products or plans with similar demographics that is actuarially appropriate.

Quantitative Treatment Limits

Quantitative treatment limitations – expressed numerically. Examples are day and visit limits

Same predominant and substantially all test as financial requirements

Quantitative treatment limits cannot accumulate separately

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Non-quantitative Treatment Limits: Defined

Non-quantitative treatment limitations are limitations that affect the scope or duration of benefits under the plan that is not expressed numerically. Any processes, strategies, evidentiary standards or other factors used in applying the

non-quantitative treatment limitation to mental health/substance use disorder benefits must be comparable to and applied no more stringently than the processes, strategies, evidentiary standards or other factors used in applying the limitation with respect to medical/surgical benefits in the same “classification.”

Under the Interim Final Rule, variation was allowed to the extent that recognized clinically appropriate standards of care may permit a difference.

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Non-quantitative Treatment Limits: Examples in the Final Rule

The Final Rule includes additional examples of NQTLs including (1) sub-classifications for multiple network tiers and benefits furnished on an outpatient basis; (2) variation in training and state licensing requirements; (3) medical management techniques; (4) coverage of treatment settings; (5) geographic coverage limitations; and (6) prior authorization requirements.

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Non-quantitative Treatment Limits: Provider Reimbursement and Qualifications

Provider Reimbursement Rate and Provider Qualifications Issuers and plans may consider the following in determining provider

reimbursement rates for mental health and substance use disorder providers:

Service type

Geographic market

Demand for services

Supply of providers

Provider practice size

Medicare reimbursement rates

Training, experience, and licensure of providers

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Residential Treatment, Partial Hospitalization and Intensive Outpatient Treatment

Plans and issuers must assign covered “intermediate mental health and substance use disorder benefits” to the existing six benefit classifications in the same way that they assign comparable intermediate medical/surgical benefits to those classifications.

The Final Rule requires assignment of covered services for intermediate levels of care and is not a mandate. The new Facility Type NQTL could require care in certain settings, however.

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Preventive Services

Under the Interim Final Rule, if a plan or issuer provides mental health/substance use disorder benefits in any classification, mental health/substance use disorder benefits must be provided in every classification in which medical/surgical benefits are provided.

Section 2713 of the PHSA requires non-grandfathered group health plans and issuers to provide coverage for certain preventive services without cost sharing – includes alcohol misuse screening and counseling and tobacco use screening.

The Final Rule clarifies that compliance with Section 2713 of PHSA will not require that the full range of benefits for a mental health/substance use disorder be provided under the Act.

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State Insurance Law

The Final Rule clarified that if a state law requires an issuer to offer coverage for a particular condition or offer a minimum dollar amount of mental health/substance use disorder benefits, the benefits for that condition must be provided in parity with medical/surgical benefits.

If a state mandates a mental health benefit, and requires an annual dollar limit, the annual dollar limit is preempted by the Act.

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Required Disclosure

The Final Rule requires the following disclosures:

o plan information on medical necessity criteria must be disclosed to contracting providers;

o the reason for denial of a claim for mental health/substance use disorder services must be disclosed to the participant, or the participant’s authorized representative (including authorized providers);

o information on medical necessity criteria for mental health/substance use disorder benefits (and processes, strategies, evidentiary standards, and other factors used to apply non-quantitative treatment limits) are considered plan documents under which the plan is “established or operated” that must be furnished to plan participants under section 104 of ERISA.

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No Annual Parity Analysis

Plan or issuer is not required to perform the parity analysis each plan year unless there is a change in plan benefit design, cost-sharing, or utilization that would affect a financial requirement or treatment limitation within a classification (or sub-classification).

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Key Parity Issues

Autism/ABA coverage

Treatment of transgender benefits

Coverage of residential treatment centers

Financial testing – Book of Business Testing

Reimbursement parity

Medical management – preauthorizaiton, concurrent care

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Private & Public Enforcement

MHPAEA may be enforced by both public and private parties

Public Enforcement (Federal and State) State Insurance regulators (against insurers)

HHS (against insurers and nonfederal gov’t plans)

DOL (against group health plans)

IRS (against group health plans and church plans)

Private Litigation Class actions by individual and group policyholder subscribers

Individual lawsuits by individual and group policyholders (including employers as plan fiduciaries)

Associations of providers and advocacy groups (see MHPAEA cases)

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• FAQs on MHPAEA Implementation

• Most recent proposed FAQs Part 39

• Updated compliance tool

• Earlier FAQs for MHPAEA

• Regulations

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II. DOL, HHS and Treasury guidance for MHPAEA and ERISA compliance

MHPAEA FAQs

FAQs About Mental Health and Substance Use Disorder Parity Implementation and the 21st Century Cures Act Released jointly by three departments: DOL, HHS and Treasury

DOL: Employee Benefits Security Administration (EBSA)

HHS: Centers for Medicare and Medicaid Services (CMS)

Treasury: Internal Revenue Service (IRS)

Reflects overlapping enforcement responsibilities

Different jurisdictions of IRS, EBSA, CMS over coverage providers

ERISA, the Code, and PHSA

See also: FAQs about Affordable Care Act Implementation

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Proposed MHPAEA FAQs 39

Released April 23, 2018 Comments went through June 22, 2018

Awaiting finalized FAQs

MHPAEA self-compliance tool

Reports (Part III of webinar) 2018 Report to Congress (Pathway to Full Parity)

2017 MHPAEA Enforcement Fact Sheet

Action plan for enhanced enforcement

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Updated draft model disclosure form (FAQ 1) Individuals use to request information pertaining to plan MH benefits

Updated from 2017 version

Describes MHPAEA requirements (2-page summary)

Participant selects options that describe their benefit claim denial (or general information request)

Participant selects options for specific information requested, such as plan language, decision factors, evidentiary standards

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Participant information request Group health plan generally must respond within 30 days of request

Claim denials often prompt the request But no justification is needed to make MHPAEA information request

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NQTL issues covered in FAQs 2-10 Experimental limitations

Autism Spectrum Disorder and Applied Behavioral Analysis (ABA)

Opioid use disorder & dosage limits

Prescription drug limitations

Step therapy

Reimbursement rates

Network adequacy

Medical appropriateness

ER

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Updated MHPAEA Self-Compliance Tool

Checklist tool updated for 2018

Plan sponsors can use in self-audit for MHPAEA compliance

DOL investigators use the same checklist in EBSA investigations

Covers MHPAEA obligations Whether the plan is subject to MHPAEA

Six classifications

Financial requirements

Treatment limitations, both quantitative and non-quantitative

Disclosure requirements

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MHPAEA FAQs

3 Departments (DOL, HHS, Treasury) but DOL site generally has the most easily accessible listing of all the FAQs Current link: https://www.dol.gov/agencies/ebsa/laws-and-

regulations/laws/affordable-care-act/for-employers-and-advisers/aca-implementation-faqs

Originally ACA FAQs, but many of the FAQs touch on MHPAEA MHPAEA is 3-department market reform, similar to ACA

Both integrated into ERISA, PHSA, and tax Code

Implementation happening around the same time as ACA

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MHPAEA FAQs

Part V (Dec 22, 2010) – small employers; information requests; cost exemption

Part VII (Nov 17, 2011) – preauthorization; medical management; evidentiary standards; copayments

Part XVII (Nov 8, 2013) – effective dates; NQTLs; MHPAEA coverage; medical management; information requests

Part XVIII (Jan 9, 2014) – ACA & MHPAEA

Part XXIX (Oct 23, 2015) – information requests (trade secrets)

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MHPAEA FAQs

Part 31 (Apr 20, 2016) – financial requirements and QTLs; preauthorization; information requests (potential enrollee); opioids

Part 34 (Oct 27, 2016) – NQTLs; information requests (enforcement); FRs & QTLs; opioids; preauthorization; court-ordered treatment

Part 38 (Jun 16, 2017) – information requests; eating disorders

Part 39 (proposed)

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Regulations Implementing MHPAEA

IFR released by 3 Depts in 2010, implementing MHPAEA

Final Regulations implementing MHPAEA published 2013 IRS: Treas. Reg. § 54.9812-1

TD 9640

DOL: Labor Reg. § 2590.712

HHS: 45 CFR § 146.136

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• DOL enforcement record and history

• DOL Action Plan, with HHS and IRS, re priorities and next steps

• Investigation process

• Outcomes of DOL investigations

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III. DOL parity compliance enforcement and handling health plan audits

DOL parity enforcement

EBSA closed 347 health investigations in FY 2017 3,286 health investigations closed since FY 2011

Of 347 closed investigations in 2017, 187 involved plans subject to MHPAEA (53.9%)

Of 187 investigations where MHPAEA applied in 2017, EBSA cited 92 violations for MHPAEA noncompliance (49%)

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39


EBSA closed 330 health investigations in FY 2016

Of 330 closed investigations,191 involved plans subject to MHPAEA (57.9%)

Of 191 investigations where MHPAEA applied, EBSA cited 44 violations for MHPAEA noncompliance (23%)

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41


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DOL enforcement: Back to 2010, NQTLs are the most common violation

NQTLs are about as common as all the other violations together

Frequency: a few hundred cases a year

Outcome:

In 2016, a quarter of DOL investigations had MHP violations of any type

In 2017, half of DOL investigations had MHP violations of any type

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MHPAEA enforcement Action Plan

Action Plan for Enhanced Enforcement (HHS, DOL, Treasury) EBSA to continue enforcement against employer plans

CMS enforces against nonfed gov plans (and insurers, with the states)

EBSA is establishing dedicated MHPAEA enforcement teams investigations of behavioral health organizations & insurance companies

DOL updated self-compliance checklist re NQTLs and disclosure

Regulatory focus on disclosure requirements to participants

Parity Portal for consumers to determine if parity violation occurs www.hhs.gov/parity

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DOL MHPAEA Audits

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Comprehensive MHPAEA audits—which focus on issuers when group health plan is insured. Some investigations of insurer’s entire book of business

What’s Being Examined? Parity of financial benefits/cost-sharing

Comparison of treatment limits for med/surgical and MH/SUD benefits

Comparison of NQTLs for med/surgical and MH/SUD benefits

Disclosure of denied/partially denied mental health/substance use disorder claims

All external review decisions relating to MH/SUD claims

Analyses by plan or issuer re: testing of NQTL for parity

Autism benefits

DOL Audits – Enforcement Authority

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DOL authority is very broad DOL does not need reasonable cause to investigate

Investigation can focus on any party

Subpoena power

Audit can lead to penalties through other agencies Example: DOL often shares information with IRS

DOL Audits – Enforcement Priorities

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Financial Requirement Testing

NQTLs – Medical Management, RTC

Disclosures

Claims review Accuracy and timing

DOL Audits – Document Request

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Plan documents in effect

Summary plan description

Trustee or fiduciary committee minutes

Form 5500/Summary Annual Report

All correspondence with plan service providers, or relating to any plan matter

Sponsor annual reports, contracts with insurers

Detailed documentation of plan administrative expenses

Fidelity bond and fiduciary liability policies

List of sponsor’s officers, board of directors

Other plan materials (Trust and participation agreements, plan merger documents, participant

contribution records, investment policy, plan receipt and disbursement journals)

DOL Audits – Potential Outcomes

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Voluntary Compliance notice letter (“10-Day letter”) describes violations and “invites” correction

Settlement agreement DOL’s claim for ERISA violation is released in return for cash or property tendered to

a plan, participant, or plan beneficiary

Results from negotiation between parties regarding implementation of correction

Penalty likely applies with respect to settlement amount

Closing letters No violations

No action warranted - Even though violations may have been identified

Compliance achieved - Violations were identified and correction may have been made to DOL’s satisfaction

• P r iv at e enfor cem ent l i t igat ion

• DOL has been slow to litigate enforcement of MHP

• Private litigation is enforcing MHP• M ajor issu es

• Treatment exclusions & limitations• Autism and applied behavior analysis (ABA)

• Addiction and residential treatment centers (RTC)

• Transgender-related benefits

• Reimbursement rates

• Preauthorization

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IV. Class action lawsuits and preventative methods to avoid them

Class action MHPAEA lawsuits - ABA

Applied behavioral analysis (ABA) Incredibly broad discipline, not just autism treatment

Common point of contention in health plans re autism treatment

ABA acceptance Increasingly common in health plans

Employees may demand coverage; ABA is generally very expensive

State law may require ABA coverage in insurance

Missouri fined Aetna $1.5M in 2012 and $4.5M in 2015 for failure to cover autism spectrum disorder, including ABA therapy

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Excluding ABA from group health plan MHPAEA allows a plan to exclude ABA as experimental/investigative

This is a nonquantitative treatment limitation

The standard for experimental/investigative must be the same for medical/surgical benefits as for ABA and MH/SUD benefits

ABA exclusion in MHPAEA FAQs, Part 39 Q/A-2 covered a discriminatory exclusion of ABA as experimental

Plan definition of experimental must be consistent for medical & MH

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Autism exclusion MHPAEA does not necessarily require autism coverage

State law often mandates autism coverage, where applicable

Employees may expect or demand autism coverage

Is autism mental health? Autism might not be per se mental health (FAQs 39 sidestepped)

Courts have held it is MH for at least some purposes; state laws have

DSM and ICD define as developmental disability

Plan should be clear if taking position autism is not mental health

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A.F. v. Providence Health Plan (D. Or. 2014) Class certified & case decided

Case was decided against Providence

Anthem developmental disability exclusion for ABA therapy

Developmental disability exclusion violates MHPAEA (& Oregon law)

Developmental disabilities are mental health conditions for MHPAEA Looked at Oregon state law, cf. NJ state law, federal law

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Wilson v. Anthem (W.D. Ky.) Class certified

Anthem limits coverage for autism

1,000 hrs/yr for ages 1-6

20 hrs/mo for ages 7-21

Plaintiff alleges QTL and annual limit violations

Anthem argued autism may not be MH in all states and may vary by individual and so mental health cannot be answered class-wide

Court certified class; autism & MH is a common question to the class

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Graddy v. Blue Cross Blue Shield (E.D. Tenn. 201) Class denied

Denial of coverage for ABA

Claims needed individualized assessments, so class denied

More cases pending Categorical exclusions of ABA

Medical necessity and ABA

Categorical exclusion of autism

Age and frequency QTLs on treatment

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Extensive settlements over ABA; not an exhaustive list Many of these are standalone insurers, not employer GHPs

State law generally always applies to insurer coverage

Settlements (2014): Premera Blue Cross (W.D. Wash.) Class certified

Federal W.D. Wash., also 2 state court cases in WA

$3.5M settlement

Premera BC agreed to end outright exclusions for autism treatment and remove age-based limitations

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Settlement (2014): Churchill v. Cigna (E.D. Pa.) Class certified

Cigna excluded ABA therapy from standard plans

$2.4M for 400 class members

Settlement (2015): C.S. v. Boeing Master Welfare Plan (W.D. Wash.) Class certified

Employer group health plan

No covered providers offered ABA therapy

Allegation: plan excluded all ABA with hidden limitations and exclusions

$900,000 for 1,400 claims

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Settlement (2016): A.P. v. T-Mobile USA EB Plan (W.D. Wash.) Class certified


$677k for 550 class members

Plan to cover ABA without caps, limits or exclusions

Settlement (April 2018): W.P. v. Anthem (S.D. Indiana) Class certified

Anthem limited hours of ABA therapy covered for children 7+

$1.625M settlement for 200 class members

Anthem to stop using guidelines limiting ABA based on age

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ABA/autism takeaways State law, if applicable to the group health plan

Age-based limitations on ABA

Flat exclusion after certain age

Hours or sessions limit is QTL and must be equivalent to medical benefits

Medical necessity is NQTL; must use same standard applied to medical

Categorical exclusions likelier to be certified

Medical necessity may require individualized proof (no class)

Medical necessity versus categorical exclusions

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Class action MHPAEA lawsuits - RTC

Residential Treatment Centers Live-in health care facility outside a hospital

Treatment for substance abuse, mental illness, behavioral problems

Alcohol and drug dependency

Eating disorders, anorexia, obesity

Other mental health or personality disorder issues

For MHPAEA purposes, commonly litigated

Wilderness therapy RTC meets Outward Bound

Therapy in a context of hiking/camping context, plus outdoor education

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RTC litigation issues Medical necessity and whether patient could be treated elsewhere

E.g. out-patient treatment rather than in-patient RTC

Medical necessity over time, after receiving a level of care

How long of an RTC stay was medically necessary?

Does the RTC meet the plan definition?

Is the treatment provided by appropriate medical professionals?

Is wilderness treatment medically necessary?

Is wilderness therapy covered as RTC?

62


Daniel F. v. Blue Shield of Cal. (N.D. Cal. 2014) Class denied

Denial of coverage for residential treatment center

Ascertainability would necessitate individualized inquiries to see whether an individual was wrongly denied RTC coverage

Takeaway: individualized medical necessity determinations can avoid class certification

63


Welp v. Cigna (S.D. Fla. 2017) Case dismissed; proposed class never certified


Wilderness therapy denied based on lack of doctors and licensed therapists sufficient to meet the standards of psychiatric RTCs

Case dismissed because plaintiff did not provide a medical/surgical analogue to demonstrate lack of parity for mental health benefits

Takeaway: claim denial over trained/licensed professionals, which is a NQTL; must expect same for medical benefits

64


William G. v. United Healthcare (D. Utah) Case still ongoing against employer GHP

Multiple wilderness treatment centers denied; preauthorization

Motion to dismiss on SOL grounds denied due to notice failure

Denial letter from plan did not disclose the limitations period, as required by Labor Reg. 2560.503-1(g)(1)(iv), so SOL defense rejected

Takeaway: make sure plan denial letters are compliant in form

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Joseph F. v. Sinclair (D. Utah 2016) Case decided against health plan

Categorical exclusion of RTC

Plan argued RTC exclusion applies to both mental health and medical benefits, so does not violate parity (parties agree to treat as NQTL)

Court: plan definition of RTC is exclusively mental health coverage

Takeaway: review categorical exclusions for parity effects

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Michael P. v. Aetna Life Ins. Co. (D. Utah, 2017) Case decided in favor of employer GHP

RTC coverage required RTC be licensed under Aetna criteria and be supervised by licensed psychiatrist; RTC facility at issue was neither

Court: if the licensing requirements are clinically appropriate with regard to RTCs, then no disparity even if it reduces MH treatment

Takeaway: medical necessity can survive disparate outcomes

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Settlement: Craft v. Health Care Serv. Corp. (N.D. Ill. 2015) Class certified

$5.25M settlement

Court: RTC exclusion resulted in less coverage of medically necessary care than that covered for medical benefits

Note: This seems directly at odds with Michael P. v. Anthem, but defendant here failed to define RTC coverage based on medical necessity

Takeaway: medical necessity is safer than categorical exclusion

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Other RTC issues being litigated: Categorical exclusion of RTCs

Precertification

RTC litigation takeaways Medical necessity is safer than categorical exclusion

Individualized necessity determinations can avoid class certification

Licensing requirements for RTCs

Review categorical exclusions for parity effects

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Class action MHPAEA lawsuits

Other issues

Reimbursement rates: New York State Psychiatric Association allowed to sue Anthem over reimbursement

rates

Associations can litigate under MHPAEA to serve corporate purpose

Eating disorders See FAQs Part 38; eating disorders are mental health conditions and eating disorder

coverage is a mental health benefit under MHPAEA

Opioid addiction and treatment

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• Comprehensive Review of MHPAEA compliance

• Either conduct in house or through counsel/consultants

• Eliminates significant M H P A E A c o m p l i a n c e r i s k

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V. Best practices for conducting internal audits of group health plans for MHPAEA compliance

Internal Audits

Classifications How is the plan classifying benefits

Are criteria used and applied consistently

Are there any red flags (i.e., all lab benefits are considered medical)?

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Internal Audits

Financial Requirements The basics – Does the plan have support under the “substantially all” and

“predominant level” tests for cost shares imposed on MH/SUD benefits.

What methodology did the plan/issuer use.

How frequently is the testing updated?

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Internal Audits

Step 1 – Identify NQTLs that apply to MH/SUD benefits

Step 2 – Review why/how the plan imposes them on MH/SUD benefits

Step 3 – Document the analysis supporting the NQTL

Step 4 – Update policies and procedures to bolster that analysis

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Internal Audits

Disclosures Does the plan have the ability to respond to requests under 104(b) of ERISA

regarding NQTL compliance?

Can the plan provide supporting documents in the event of a benefits denial?

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Questions?

Ryan TemmeGroom Law Group

Washington, [email protected]

Chris WelschWinston & Strawn LLP

Chicago, [email protected]

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