Medicaid and Children’s Health Insurance Program managed care organizations that offer mental health and substance use disorder benefits are required to provide coverage that is comparable to their coverage for general medical and surgical care.

Achieving parity between medical and surgical (MS) care, and mental health and substance use disorder (MHSUD) care means limitations on MHSUD benefits (such as copayments, visit limits and preauthorization requirements) must generally be comparable with those for MS benefits.

Managed care organizations must demonstrate parity in:

  • Aggregate lifetime and annual dollar limits. Aggregate lifetime dollar limits specify the total amount that may be paid on benefits. Annual dollar limits specify the amount — including monthly dollar limits — that may be paid in a 12-month period on benefits.
  • Financial requirements. Payments by beneficiaries for services including copayments, coinsurance and deductibles.
  • Quantitative treatment limitations. Limits on the scope or duration of a benefit that are expressed numerically. This includes day or visit limits.
  • Non-quantitative treatment limitations. Limits on the scope or duration of benefits and services that are not expressed numerically such as prior authorizations requirements;
  • Availability of information. The different documents beneficiaries are entitled to receive related to mental health and substance use disorder and medical/surgical benefits.

Background

On March 29, 2016, the Centers for Medicare & Medicaid Services issued the Medicaid and CHIP Mental Health Parity Final Rule. This rule applies certain provisions of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act to requirements for Medicaid managed care organizations and the Children’s Health Insurance Program.

MHPAEA is a federal law that generally prevents managed care organizations that provide MHSUD benefits from imposing less favorable benefit limitations on those benefits than on MS benefits.

The original compliance date was Oct. 2, 2017; however CMS granted the state an extension until Dec. 2, 2017.