Appendix II for Supporting Statement

Appendix II: Crosswalk of Changes

Medical Necessity and Claims Denial Disclosures under MHPAEA

(CMS-10307/OMB Control No. 0938-1080)

On June 16, 2017, the Departments issued FAQs About Mental Health And Substance Use Disorder Parity Implementation And The 21st Century Cures Act Part 38, which, among other things, solicited comments on a draft model form that participants, enrollees, or their authorized representatives could -- but would not be required to -- use to request information from their health plan or issuer regarding NQTLs that may affect their MH/SUD benefits, or to obtain documentation after an adverse benefit determination involving MH/SUD benefits to support an appeal. The Departments made the following changes to the draft model form in response to comments received.

Section Edited	Revision (Red indicates modified Language)
Background	This is a tool to help you request information from your employer-sponsored health plan or your insurer regarding limitations that may affect your access to mental health or substance use disorder benefits. You can use this form to request general information about treatment limitations or specific information about limitations that may have resulted in denial of your benefits.
Background	Added: An example of a request for general information might be a request for the plan’s preauthorization policies for medical/surgical and mental health treatments. An example of a request for specific information related to a denial of benefits based on a failure to show medical necessity might be a request for the internal medical necessity guidelines used to deny your claim.
Background	Under a federal law called the Mental Health Parity and Addiction Equity Act (MHPAEA), many health plans and insurers must make sure that there is “parity” between mental health and substance use disorder benefits, and medical and surgical benefits.
Background	This generally means that treatment limits applied to mental health and substance use disorder benefits must be at least as generous as the treatment limits applied to medical and surgical benefits. In other words, treatment limits cannot be applied to mental health and substance use disorder benefits unless those limits are comparable to limits applied to medical and surgical benefits.
Instructions	Complete the attached form to request general information from your plan or insurer about coverage limitations or specific information about why your mental health or substance use disorder benefits were denied. This information can help you appeal a claim denial but you must initiate the plan’s general review and appeals process if you want to appeal with your plan or insurer the claim denial.
Instructions	Added: Consult your summary plan description (SPD) or certificate of coverage to see how to request information from the plan. If you are helping someone with obtaining information about his/her health coverage, you are often required to submit an authorization along with this form signed by the person you are helping if you have not submitted one beforehand.
Form	Added: Attached to this request is an authorization signed by the enrollee.
Form	I am requesting information concerning the plan’s limitations related to coverage for: Mental health and substance use disorder benefits, generally. The following specific treatment for my condition or disorder:
Form	Based on your understanding of the denial of, limitation on, or reduction in coverage, check all that apply)
Form	Added: The plan requires ongoing authorizations before it will cover my continued treatment.
Form	The plan is requiring me to try a different treatment before authorizing the treatment that my doctor recommends.
Form	My plan covers my mental health or substance use disorder treatment, but does not have any reasonably accessible in-network providers for that treatment. I am not sure how my plan calculates payment for out-of-network services, such as its methods for determining usual, customary and reasonable charges, complies with parity protections.
Form	Because my health coverage is subject to the parity protections, treatment limits cannot be applied to mental health and substance use disorder benefits unless those limits are comparable to limits applied to medical and surgical benefits. Therefore, for the limitations or terms of the benefit plan specified above, within thirty (30) calendar days of the date appearing on this request, I request that the plan: 2. Identify the factors used in the development of the limitation (examples of factors include, but are not limited to, excessive utilization, recent medical cost escalation, high variability in cost for each episode of care, and safety and effectiveness of treatment);
Form	Added: 3. Identify the evidentiary standards used to evaluate the factors. Examples include, but are not limited to, the following: Excessive utilization as defined by two standard deviations above average utilization per episode of care; Recent medical cost escalation as defined by medical costs for certain services increasing 10% or more per year for 2 years; High variability in cost per episode of care as defined by episodes of outpatient care being 2 standard deviations higher in total costs than the average cost per episode 20% or more of the time in a 12-month period; and Safety and efficacy of treatment modality as defined by 2 random clinical trials required to establish a treatment is not experimental or investigational;
Form	5. Provide any evidence and documentation to establish that the limitation is applied no more stringently, as written and in operation, to mental health and substance use disorder benefits than to medical and surgical benefits.
Form	Added: I am an authorized representative requesting information for the following individual enrolled in the plan: ______________________________________. Attached to this request is an authorization signed by the enrollee.
Form	Added: E-mail address (if email is a preferred method of contact)