The Act generally requires equity in treatment of mental health and substance abuse treatments under a plan. It applies to plans with coverage for 50 or more employees and the key components of the Act are as follows:
1. Plans cannot impose more restrictive lifetime or annual limits on mental health or substance use disorder benefits than those imposed on medical or surgical benefits
2. Plans cannot impose more restrictive financial requirements, such as co-pays, deductibles, coinsurance or out-of-pocket expenses, on treatment for mental health or substance use disorder benefits than what is imposed on medical or surgical benefits
3. Plans cannot impose more restrictive limitations on the frequency or total use of mental health or substance use disorder benefits than what is imposed on medical or surgical benefits; such as limits on frequency of treatment, limits on number of visits, limits on number of days of coverage
4. Plans must provide similar in-network and out-of-network benefits for all coverages
5. Plans must provide participants with the criteria used for determining medical necessity of mental health and substance use benefits.
Also, if a plan offers two or more benefits packages, for example, services for mental health conditions and services for substance use disorders, the requirements apply separately to each package. As for exceptions, a plan can be exempted from the Act if it experiences an increase in actual total costs of 1% (2% in the first plan year that the Act applies). Any request for exemption to the Department of Labor or Department of Health & Human Services will require actuarial certification (which is proof from a specialist in insurance calculations) of the cost increase associated with the implementation of the Act.
