NQTL Audit Service

On-Demand Assistance

If you have reached this site, you are likely already aware of a new requirement for employer plan sponsors and health insurance carriers.  In December of 2020, a bill was passed which requires additional, complex documentation and comparative analysis on both the quantitative treatment limits of plans as well as the non-quantitative limits on plans. 

These are new requirements under the Mental Health Parity and Addiction Equity Act.

Where did this come from?

Simply put, the Department of Labor was less than pleased with the results of audits conducted in regard to MHPAEA compliance and they set out to do something about it.  One of the major issues at hand was that often plans were designed on the surface to have parity between medical/surgical benefits and mental health/substance abuse (MH/SUD), however when you looked at how the plan operated they were not in parity.

One simple example would be pre-certification for an inpatient stay.  A plan might have the same deductible for medical/surgical as MH/SUD, but if the pre-certification process is much more stringent for MH/SUD they really are not in parity in the application of the plan operations.

What is the new requirement?

NQTL Comparative Analysis

Documentation must be available to plan members and the DOL upon request beginning February 10th, 2021.  Documentation must include the following type of items:

  • Terms — the specific plan and coverage terms on NQTLs for MH/SUD and M/S benefits and a description of these benefits, including which of the six parity classifications contains the benefit (i.e. inpatient in network, outpatient in network, Inpatient Out-of-Network, Out Patient out-of-network, Emergency Care, and Pharmacy)
  • Evidentiary standards —the evidentiary standards and any other sources on which the plan relied to back up the factors used to design the NQTL and justify its application to a benefit (see chart below for examples)
  • Factors —the factors used to determine that the NQTLs should apply to the benefits
  • Comparative analysis —a separate analysis of each NQTL for benefits in each classification “demonstrating that the processes, strategies, evidentiary standards and other factors used to apply the NQTLs” to MH/SUD benefits (in written terms and plan operations) are “comparable to and applied no more stringently” than those used to apply NQTLs to M/S benefits
  • Findings and conclusions —the results of the comparative analysis giving the plan’s or issuer’s specific findings on what is and is not in compliance with the parity law

Want to get Nerdy?

MHPAEA, 2021 Part 45

This is an 8 page document that will be helpful for evaluating your compliance standing. 

Download document here.

Specifically, the analysis must include at least nine elements listed in the guidance:

    1. A clear description of the specific NQTL, plan terms, and policies at issue.
    2. Identification of the specific MH/SUD and medical/surgical benefits to which the NQTL applies within each benefit classification, and a clear statement as to which benefits identified are treated as MH/SUD and which are treated as medical/surgical.
    3. Identification of any factors, evidentiary standards or sources, or strategies or processes considered in the design or application of the NQTL and in determining which benefits, including both MH/SUD benefits and medical/surgical benefits, are subject to the NQTL. Analyses should explain whether any factors were given more weight than others and the reason(s) for doing so, including an evaluation of any specific data used in the determination.
    4. To the extent the plan or issuer defines any of the factors, evidentiary standards, strategies, or processes in a quantitative manner, it must include the precise definitions used and any supporting sources.
    5. The analyses, as documented, should explain whether there is any variation in the application of a guideline or standard used by the plan or issuer between MH/SUD and medical/surgical benefits and, if so, describe the process and factors used for establishing that variation.
    6. If the application of the NQTL turns on specific decisions in administration of the benefits, the plan or issuer should identify the nature of the decisions, the decision maker(s), the timing of the decisions, and the qualifications of the decision maker(s).
    7. If the plan’s or issuer’s analyses rely upon any experts, the analyses, as documented, should include an assessment of each expert’s qualifications and the extent to which the plan or issuer ultimately relied upon each expert’s evaluations in setting recommendations regarding both MH/SUD and medical/surgical benefits.
    8. A reasoned discussion of the plan’s or issuer’s findings and conclusions as to the comparability of the processes, strategies, evidentiary standards, factors, and sources identified above within each affected classification, and their relative stringency, both as applied and as written. This discussion should include citations to any specific evidence considered and any results of analyses indicating that the plan or coverage is or is not in compliance with MHPAEA.
    9. The date of the analyses and the name, title, and position of the person or persons who performed or participated in the comparative analyses.