Mental Health & Substance Use Disorder Benefits

Did you know that mental illness affects millions of people in the United States each year? Nearly one in five adults live with a mental illness. An estimated 49.5% of adolescents between the ages of 13 and 18 have a mental disorder. Substance abuse also affects millions of people each year in the United States.

As an Ambetter from Sunshine Health member, your plan provides coverage for Mental Health and Substance Use Disorder services at parity with Medical and Surgical services, in accordance with the Federal Mental Health Parity and Addiction Equity Act (MHPAEA).

You can read more about the MHPAEA: cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet

In 2021, the Florida Legislature passed HB 701, which requires disclosure to you on your required benefits for Behavioral and Mental Health.

Additionally, Florida has resources for you if you are concerned about your benefits. To report complaints about the availability, affordability and adequacy of behavioral health care services, please call the Department of Financial Services at 1-877-MY-FL-CFO (1-877-693-5236). If you are calling from outside Florida, please call 1-850-413-3089.

For more information, visit https://www.myfloridacfo.com/Division/Consumers/needourhelp.htm

Below are the requirements from the MHPAEA and Florida Statutes:

REQUIREMENT	REFERENCE	DESCRIPTION OF STANDARDS OR REQUIREMENTS
Defining Mental Health/Substance Use Disorder benefits (MH/SUD)	42 U.S.C. 300gg-26 42 U.S.C. 18031(j) 45 CFR 146.136(a) 45 CFR 156.115(a)(3)	The policy or contract shall define mental health benefits or substance use disorder benefits to mean items or services for the treatment of a mental health condition or substance use disorder, as defined by the policy or contract or applicable state law. Any condition or disorder defined as not a mental health condition or substance use disorder must be consistent with generally recognized independent standards of current medical practice and applicable state law.
Classifying benefits	42 U.S.C. 300gg-26 42 U.S.C. 18031(j) 45 CFR 146.136(c)(2)(ii)(A) 45 CFR 146.136(c)(3)(iii)(A) 45 CFR 146.136(c)(3)(iii)(B) 45 CFR 146.136(c)(3)(iii)(C) 45 CFR 156.115(a)(3)	The issuer shall assign MH/SUD benefits to each of the six classifications and permitted sub-classifications. The issuer must apply the same standards to medical/surgical benefits and to mental health or substance use disorder benefits in determining the classification or sub-classification in which a particular benefit belongs. The issuer shall demonstrate that mental health or substance use disorder benefits are covered in each classification in which medical/surgical benefits are covered.
Financial requirements and quantitative treatment limitations	42 U.S.C. 300gg-26(a)(3)(A) 42 U.S.C. 18031(j) 45 CFR 146.136(c)(2)(i) 45 CFR 146.136(c)(3)(i)(A) 45 CFR 146.136(c)(3)(i)(B)(1) 45 CFR 146.136(c)(3)(i)(B)(2) ACA FAQ 34 Q3 45 CFR 156.115(a)(3)	The policy or contract shall not apply any financial requirement or quantitative treatment limitation on mental health or substance use disorder benefits in any classification (or applicable sub-classification) that is more restrictive than the predominant financial requirement or quantitative treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification (or applicable sub-classification).
Cumulative financial requirements and cumulative quantitative treatment limitations	42 U.S.C. 300gg-26(3) 45 CFR 146.136(c)(3)(v)	The issuer shall not apply any cumulative financial requirement or quantitative treatment limitation to mental health or substance use disorder benefits in a classification that accumulates separately from any established for medical/surgical benefits in the same classification.
Nonquantitative treatment limitations (NQTLs)	42 U.S.C. 300gg-26(a)(3)(A) 42 U.S.C. 18031(j) 45 CFR 146.136(c)(4)(i) 45 CFR 156.115(a)(3)	The issuer shall justify the application of any NQTL to mental health or substance use disorder benefits within a classification of benefits (or applicable sub-classification) such that any processes, strategies, evidentiary standards, or other factors used to apply a limitation, as written and in operation, are comparable to, and are applied no more stringently, than the processes, strategies, evidentiary standards, or other factors used to apply the limitation to medical/surgical benefits within the classification (or applicable sub-classification). NQTLs shall be categorized as such: medical management- which includes issuer prior authorization, concurrent review and retrospective review protocols and the medical necessity criteria utilized in conjunction with them; exclusions of coverage; e.g., experimental or investigational; plan provider network matters- credentialing criteria, network tiering; network adequacy; i.e. plan MH/SUD network performance; provider reimbursement rates; prescription drugs; other NQTLs as identified by the issuer- restrictions on facility type, geographic location.
Disclosure	42 U.S.C. 300gg-26(a)(4) 45 CFR 146.136(d)(1) 45 CFR 146.136(d)(2) 45 CFR 146.136(d)(3) 45 CFR 147.136(b)(2) 45 CFR 147.136(b)(3)	The issuer shall ensure that it complies with all availability of policy or contract information and related disclosure obligations regarding: criteria for medical necessity determinations; reasons for denial of services; information relevant to medical/surgical, mental health, and substance use disorder benefits rules regarding claims and appeals, including the right of claimants to free reasonable access and copies of documents, records and other information including information on medical necessity criteria for both medical/surgical benefits and mental health and substance use disorder benefits, as well as the processes, strategies, evidentiary standards, and other factors used to apply a NQTL with respect to medical/surgical benefits and mental health or substance use disorder benefits under the plan.
Issuer coordination with vendors	78 FR 68250	If the issuer contracts with a managed behavioral health organization (MBHO) to provide any or all of the issuer’s mental health or substance use disorder benefits it shall ensure that it coordinates with the MBHO to secure compliance with MHPAEA.
Documentation of Comparative Analysis for NQTLs	Section 203 of the Consolidated Appropriations Act, 2021 (CAA) amends PHSA —Section 2726(a) of the Public Health Service Act: 42 U.S.C. 300gg–26(a)	Revises ERISA, PHSA, and the tax code to require plans and issuers to conduct comparative analyses to document their compliance with the existing rules governing NQTLs under MHPAEA.

Florida also has requirements that ensure Insurers follow the Federal requirements listed above. In addition, Florida Statutes 627.668 (2) has the following requirements for group policies or contracts as it relates to durational limits, dollar amounts deductibles and coinsurance.

REQUIREMENT	REFERENCE	DESCRIPTION OF STANDARDS OR REQUIREMENTS
Inpatient hospital benefits	627.668 (2)(a) F.S.	Inpatient hospital benefits consisting of durational limits, dollar amounts, deductibles, and coinsurance factors shall not be less favorable than for physical illness generally, except that: inpatient benefits may be limited to not less than 30 days per benefit year as defined in the policy or contract. If inpatient hospital benefits are provided beyond 30 days per benefit year, the durational limits, dollar amounts, and coinsurance factors thereto need not be the same as applicable to physical illness generally.
	627.668 (2)(b) F.S.	Outpatient benefits consisting of durational limits, dollar amounts, deductibles, and coinsurance factors shall not be less favorable than for physical illness generally, except that: outpatient benefits may be limited to $1,000 for consultations with a licensed physician, a psychologist licensed pursuant to chapter 490, a mental health counselor licensed pursuant to chapter 491, a marriage and family therapist licensed pursuant to chapter 491, and a clinical social worker licensed pursuant to chapter 491. If benefits are provided beyond the $1,000 per benefit year, the durational limits, dollar amounts, and coinsurance factors thereof need not be the same as applicable to physical illness generally.
	627.668 (2)(c) F.S.	Partial hospitalization benefits consisting of durational limits, dollar amounts, deductibles, and coinsurance factors shall not be less favorable than for physical illness generally, except that: partial hospitalization benefits shall be provided under the direction of a licensed physician. For purposes of this part, the term “partial hospitalization services” is defined as those services offered by a program that is accredited by an accrediting organization whose standards incorporate comparable regulations required by this state. Alcohol rehabilitation programs accredited by an accrediting organization whose standards incorporate comparable regulations required by this state or approved by the state and licensed drug abuse rehabilitation programs shall also be qualified providers under this section. In a given benefit year, if partial hospitalization services or a combination of inpatient and partial hospitalization are used, the total benefits paid for all such services may not exceed the cost of 30 days after inpatient hospitalization for psychiatric services, including physician fees, which prevail in the community in which the partial hospitalization services are rendered. If partial hospitalization services benefits are provided beyond the limits set forth in this paragraph, the durational limits, dollar amounts, and coinsurance factors thereof need not be the same as those applicable to physical illness generally.

Mental Health & Substance Use Disorder Benefits

Requirements from the Federal Mental Health Parity and Addiction Equity Act (MHPAEA) nd Florida Statutes)