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Departments Enforce Protections for Autism Treatments Under the MHPAEA

The Department of Labor (DOL), along with the Departments of Health and Human Services (HHS) and the Treasury, have made compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) a top priority.

Recently, the DOL’s Employee Benefit Security Administration (EBSA) has taken a strong stance in favor of interpreting MHPAEA coverage rules to include treatments for autism spectrum disorder (ASD), including Applied Behavior Analysis (ABA) therapy. In a blog posted on April 13, 2023, EBSA Assistant Secretary, Lisa M. Gomes, reaffirmed the agency’s commitment to ensuring the people with autism can access autism treatment benefits.

MHPAEA requires group health plans and issuers that offer mental health benefits to ensure parity between medical/surgical benefits and mental health or substance use disorder benefits regarding financial requirements (e.g., coinsurance and copayments) and treatment limitations (such as visit limits), in addition to nonquantitative treatment limitations (NQTLs) (e.g., coverage exclusions, prior authorization requirements, and medical necessity). The quantitative and NQTLs for mental health and substance abuse disorders generally cannot be more restrictive than the limitations applied to medical and surgical benefits.

Many group health plans often cover benefits for autism as part of their mental health benefits. These benefits, such as those for treatment of ABA therapy, are protected under MHPAEA. In its 2022 MHPAEA Report to Congress, EBSA noted that limitations on ABA and other treatments for ASD were the fourth most requested type of comparative analyses by EBSA. Significantly, 100% of these requested compliance reviews resulted in an initial finding on noncompliance with MHPAEA.

The noncompliant plans were required to take corrective action, including the removal or reduction of NQTLs that limit treatment or benefits, additional coverage for benefits that were previously excluded, and notice to participants and beneficiaries of these changes in plan terms.

EBSA has made it clear it is committed to working with plans, health insurers, service providers and families to ensure individuals with ASD have access to affordable, quality coverage. As described in this prior blog post, plans should also perform and record a comparative analysis of the NQTLs each year for their plan and be aware that the DOL may request a copy of this report upon audit.

The DOL offers a self-compliance tool for the MHPAEA that plans can use to review their compliance approach but employers are encouraged to work with their carriers and/or third-party administrators to ensure compliance with MHPAEA, not only with respect to covered benefits for ASD, but all mental health and substance abuse disorder benefits

For additional compliance news, check out our monthly compliance roundup here: What We’re Watching: Employer Compliance Across Benefits, HR, and Retirement.