FAQS ABOUT MENTAL HEALTH AND 
SUBSTANCE USE DISORDER PARITY 
IMPLEMENTATION AND THE 21ST CENTURY 
CURES ACT PART 39 
September 5, 2019 
Below are responses to additional frequently asked questions (FAQs) regarding implementation 
of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 
2008 (MHPAEA), as amended by the Affordable Care Act.  The responses to FAQs also address 
implementation of the 21st Century Cures Act (Cures Act), the SUPPORT for Patient and 
Communities Act (Support Act), and the Employee Retirement Income Security Act (ERISA). 
These FAQs have been prepared jointly by the Departments of Labor (DOL), Health and Human 
Services (HHS), and the Treasury (collectively, the Departments).  As with previously issued 
FAQs (available at https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-
care-act and www.cms.gov/cciio/resources/fact-sheets-and-faqs/index.html), these FAQs are 
designed to help people understand the law and benefit from it as intended through examples that 
illustrate the requirements of MHPAEA and its implementing regulations. While some of the fact 
patterns used as examples may be relatively uncomplicated, they should enable the public to 
identify and address important MHPAEA issues.  These FAQs do not contain any new 
interpretations of MHPAEA, but instead provide additional examples of how the MHPAEA final 
regulations apply to different fact patterns to promote compliance. 
Mental Health Parity and Addiction Equity Act of 2008 and the 21st Century Cures Act 
In general, MHPAEA requires that the financial requirements (such as coinsurance and copays) 
and treatment limitations (such as visit limits) imposed on mental health or substance use 
disorder (MH/SUD) benefits cannot be more restrictive than the predominant financial 
requirements and treatment limitations that apply to substantially all medical/surgical benefits in 
a classification.1 
With regard to any nonquantitative treatment limitation (NQTL), the MHPAEA final regulations 
provide that a group health plan or health insurance issuer may not impose an NQTL with 
respect to MH/SUD benefits in any classification unless, under the terms of the plan (or health 
insurance coverage) as written and in operation, any processes, strategies, evidentiary standards, 
or other factors used in applying the NQTL to MH/SUD benefits in the classification are 
comparable to, and are applied no more stringently than, the processes, strategies, evidentiary 
                                                 
 
1 The six classifications of benefits defined in final rules implementing the requirements of MHPAEA are: (1) 
inpatient, in-network; (2) inpatient, out-of-network; (3) outpatient, in-network; (4) outpatient, out-of-network; (5) 
emergency care; and (6) prescription drugs. 26 CFR 54.9812-1(c)(2)(ii); 29 CFR 2590.712(c)(2)(ii); and 45 CFR 
146.136(c)(2)(ii). 
1  standards, or other factors used in applying the limitation to medical/surgical benefits in the same 
classification.  MHPAEA also imposes certain disclosure requirements on group health plans and 
health insurance issuers offering group or individual health insurance coverage. 
The Cures Act requires the Departments to solicit feedback and issue guidance regarding the 
disclosure and NQTL requirements of MHPAEA. Section 13001(b) of the Cures Act specifically 
requires that the Departments issue clarifying information and illustrative examples of methods 
that a plan or issuer offering group or individual health insurance coverage can use to disclose 
information in compliance with MHPAEA.  Section 13001(b) also directs the Departments to 
issue clarifying information and illustrative examples of methods, processes, strategies, 
evidentiary standards, and other factors that plans and issuers may use regarding the 
development and application of NQTLs such as: 
1.  Medical management standards based on medical necessity or appropriateness, or 
whether a treatment is experimental or investigative; 
2.  Limitations with respect to prescription drug formulary design, and use of step 
therapy protocols or fail-first policies; 
3.  Network admission standards (such as credentialing);  
4.  Factors used in provider reimbursement methodologies (such as service type, 
geographic market, demand for services, and provider supply, practice size, training, 
experience, and licensure) as such factors apply to network adequacy; and 
5.  Examples of sources of information that may serve as evidentiary standards for the 
purposes of making determinations regarding the development and application of 
NQTLs. 
As part of the Departments implementation of the Cures Act, on June 16, 2017, the Departments 
issued MHPAEA compliance assistance guidance regarding benefits for eating disorder 
treatment.2 
The Departments issued several additional documents related to MHPAEA on April 23, 2018, 
including an MHPAEA self-compliance tool to aid plans, issuers, and other stakeholders in 
understanding the requirements of MHPAEA, an action plan developed by HHS, DOLs 
biannual report to Congress regarding MHPAEA implementation and enforcement efforts, and 
DOLs fiscal year 2017 MHPAEA enforcement fact sheet.3  At the same time, the Departments 
                                                 
 
2 See FAQs about Mental Health and Substance Use Disorder Parity Implementation and the 21st Century Cures Act 
Part 38, available at https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-
part-38.pdf and https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQ-Part-38.pdf. 
3 2018 MHPAEA Self-Compliance Tool, available at https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-
activities/resource-center/publications/compliance-assistance-guide-appendix-a-mhpaea.pdf; 21st Century Cures Act: 
Section 13002 Action Plan For Enhanced Enforcement of Mental Health and Substance use Disorder Coverage, 
available at https://www.hhs.gov/sites/default/files/parity-action-plan-b.pdf; DOL 2018 Report to Congress: 
2  also proposed two guidance documents with requests for comment.  The first document was a 
model disclosure request form that could be used to request information from group health plans 
and health insurance issuers offering group or individual health insurance coverage. 4  The 
second was, Proposed FAQs about Mental Health and Substance Use Disorder Parity 
Implementation and The 21st Century Cures Act Part 39. 
In addition, on January 10, 2019, the DOL, in coordination with the Departments of HHS and the 
Treasury, hosted a roundtable discussion with stakeholders to discuss issues regarding MHPAEA 
implementation, including the proposed FAQs and model disclosure request form. 
Commenters on the FAQs generally supported the Departments efforts to give additional 
guidance and compliance assistance. Stakeholders also shared important insights into certain 
compliance issues faced by plans and issuers, as well as issues faced by plan participants and 
their authorized representatives when they are seeking information about MH/SUD benefits.  
After considering these comments and making edits to clarify the guidance (including, where 
necessary, deleting language that commenters have identified as confusing or unclear), the 
Departments are issuing a final model disclosure request form and final FAQs Part 39 with 
clarifications. 
The Departments intend to continue to provide additional MHPAEA implementation information 
on a rolling basis, including revised compliance program documents and updated enforcement 
data.  For the most current information on MHPAEA, Cures Act, and Support Act 
implementation, see https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-
health-and-substance-use-disorder-parity and https://www.cms.gov/cciio. 
Nonquantitative Treatment Limitations 
An NQTL is generally a limitation, often non-numeric, on the scope or duration of benefits for 
treatment. In developing and applying an NQTL, the regulations provide that a plan or issuer 
may consider a wide array of factors.5 For example, a plan can consider economic factors, such 
as high cost growth, or other factors such as the incidence of fraud with respect to services in a 
particular classification. In applying those factors, the NQTL analysis does not focus on whether 
the final result (for example, coverage denial rates) is the same for MH/SUD benefits and 
                                                 
 
Pathway to Full Parity, available at https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-
health-parity/dol-report-to-congress-2018-pathway-to-full-parity.pdf and FY 2017 MHPAEA Enforcement Fact 
Sheet, available at https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/fact-
sheets/mhpaea-enforcement-2017.pdf. 
4 A previous version of the model disclosure request form was issued by the Departments on June 16, 2017 with a 
request for public comment.  
5 See 26 CFR 54.9812(c)(4)(iii), 29 CFR 2590.712(c)(4)(iii), 45 CFR 146.136(c)(4)(iii), example 8, outlining an 
illustrative list of factors that a plan uses to develop and apply a compliant NQTL. 
3  medical/surgical benefits; instead, compliance depends on parity in development and application 
of the underlying processes and strategies. There should not be arbitrary or discriminatory 
differences in how a plan or issuer is applying those processes and strategies to medical/surgical 
benefits and MH/SUD benefits. Moreover, in the preamble to the MHPAEA final regulations 
(which reiterates guidance issued by the Departments in 2011), the Departments stated that it is 
unlikely that a reasonable application of the NQTL requirement would result in all MH/SUD 
benefits being subject to an NQTL in the same classification in which less than all 
medical/surgical benefits are subject to the NQTL.6  While similar or dissimilar outcomes 
between MH/SUD benefits and medical/surgical benefits with respect to, for example, benefit 
denial rates are NOT determinative of compliance, higher rates of denials for MH/SUD benefits 
may be viewed as a warning sign, or indicator of potential operational parity noncompliance. 
Vast differences in such rates can serve as a strong indicator of potential noncompliance. The 
following examples illustrate how to evaluate the factors used to develop and apply an NQTL in 
a variety of fact patterns. 
Q1. My health plan document states that it excludes coverage for treatment that is 
experimental or investigative for both medical/surgical benefits and for MH/SUD benefits.  
For both medical/surgical benefits and MH/SUD benefits, the plan generally follows 
current medical evidence and professionally recognized guidelines on the efficacy of 
treatment. With respect to both medical/surgical benefits and MH/SUD benefits, the plans 
documents state that the plan excludes coverage for treatment as experimental for a given 
condition when no professionally recognized treatment guidelines define clinically 
appropriate standards of care for the condition, and fewer than two randomized controlled 
trials are available to support the treatments use with respect to the condition. 
The plan defines Autism Spectrum Disorder as a mental health condition.  More than one 
professionally recognized treatment guideline and more than two controlled randomized trials 
support the use of Applied Behavior Analysis (ABA) therapy to treat certain children with 
Autism Spectrum Disorder.  The plan, in practice, excludes coverage for ABA therapy to treat 
children with Autism Spectrum Disorder under the rationale that the treatment is experimental or 
investigative. With respect to medical/surgical conditions, the plan covers treatment when 
supported by one or more professionally recognized treatment guidelines and two or more 
controlled randomized trials.  Is this permissible under MHPAEA? 
No.  The plans application of the NQTL to MH/SUD benefits is not permissible because, in 
operation, the plan applies the NQTL more stringently to certain MH/SUD benefits than to 
                                                 
 
6 See 78 FR 68240, 68245 (Nov. 13, 2013). See also FAQs About Affordable Care Act Implementation (Part VII) 
and Mental Health Parity Implementation (November 17, 2011) at Q&A-5 
https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-vii.pdf and 
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs7.html. 
4  medical/surgical benefits.  A medical management standard limiting or excluding benefits based 
on whether a treatment is experimental or investigative is an NQTL under MHPAEA.7  A group 
health plan or group or individual health insurance issuer may impose an NQTL on MH/SUD 
benefits if, under the terms of the plan as written and in operation, the processes, strategies, 
evidentiary standards, and other factors used by the plan in applying the NQTL to MH/SUD 
benefits are comparable to, and are applied no more stringently than, the processes, strategies, 
evidentiary standards, and other factors used in applying the NQTL to medical/surgical benefits 
in the same classification. 
Although the plan as written purports to exclude experimental or investigative treatment for both 
MH/SUD and medical/surgical benefits using the same standards, in practice, it imposes this 
exclusion more stringently on certain MH/SUD benefits, as the plan excludes ABA therapy, 
despite the fact that professionally recognized treatment guidelines and the requisite number of 
randomized controlled trials support the use of ABA therapy to treat children with Autism 
Spectrum Disorder.  Accordingly, the plans exclusion of certain MH/SUD benefitsin this 
case, for ABA therapydoes not comply with MHPAEA because the plan applies the NQTL 
more stringently to these MH/SUD benefits than to medical/surgical benefits. 
To comply with MHPAEA, the plan must ensure that any processes, strategies, evidentiary 
standards, and other factors used to impose the exclusion are applied comparably to all 
medical/surgical and MH/SUD benefits in the relevant classification.  This could be 
accomplished, in practice, by not excluding as experimental or investigative any treatment that 
has professionally recognized treatment guidelines defining clinically appropriate standards of 
care for the condition and for which at least two randomized controlled trials are available to 
support the treatments use with respect to the condition. To the extent the plan determines any 
treatment should be excluded after properly applying this standard, the plan should also 
document the factors relied upon to exclude the treatment on this basis. 
Q2: My health plan documents state that the plan excludes coverage for treatment that is 
experimental or investigative for both medical/surgical benefits and for MH/SUD benefits. 
The plan defines experimental or investigative treatments as those with a rating below B 
in the Hayes Medical Technology Directory, with exceptions for certain treatments that 
have a rating of C only where an exception is determined to be medically appropriate.  
However, in operation, the plan reviews and covers certain treatments for medical/surgical 
conditions that have a rating of C only when an exception is determined to be medically 
                                                 
 
7 MHPAEA regulations at 26 CFR 54.9812-1(c)(4)(ii); 29 CFR 2590.712(c)(4)(ii); and 45 CFR 146.136(c)(4)(ii) 
contain an illustrative list of NQTLs that includes, among other things, medical management standards limiting or 
excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is 
experimental or investigative; formulary design for prescription drugs; network tier design; and plan methods for 
determining usual, customary, and reasonable charges. 
5  appropriate, while denying all benefits for MH/SUD treatment that have a rating of C or 
below, without reviewing the treatments to determine whether exceptions are medically 
appropriate. Is this permissible under MHPAEA? 
No.  A medical management standard that limits or excludes benefits based on whether a 
treatment is experimental or investigative is an NQTL under MHPAEA.8  A plan or issuer may 
impose an NQTL on MH/SUD benefits if, under the terms of the plan as written and in 
operation, the processes, strategies, evidentiary standards, and other factors used by the plan in 
applying its NQTL with respect to MH/SUD benefits are comparable to, and applied no more 
stringently than, those used in applying the NQTL with respect to medical/surgical benefits in 
the same classification. 
Here, although the terms of the plan set forth the same evidentiary standard for MH/SUD 
benefits and medical/surgical benefits (defining experimental as having a Hayes Medical 
Technology Directory rating below B, with exceptions for those with a C rating where 
medically appropriate), the plan applies a different evidentiary standard, and the standard is more 
stringent for MH/SUD benefits than for medical/surgical benefits because claims for 
medical/surgical treatments with a C rating are reviewed to determine whether an exception is 
medically appropriate while claims for MH/SUD treatments with a C rating are denied without 
review by the plan to determine whether an exception might be medically appropriate.  The fact 
that the plan ultimately denies some medical/surgical benefits that have a rating of C does not 
justify the total exclusion of treatments with a C rating for MH/SUD.  Accordingly, the plans 
medical management standard does not comply with MHPAEA. 
To comply with MHPAEA, the plan must apply the same exception for MH/SUD treatments in 
the same classification if the plan, in operation, provides an exception based on medical 
appropriateness for medical/surgical treatments. To ensure that its approach is compliant with 
MHPAEA and that it will be able to satisfy participants requests for documents, the plan should 
document in writing the availability and requirements of its exceptions process, as well as the 
factors relied upon in determining how the exception process applies to both MH/SUD and 
medical/surgical benefits. 
Q3:  My health plan documents state that the plan follows professionally recognized 
treatment guidelines when setting dosage limits for prescription medications, but the 
dosage limit set by my plan for buprenorphine to treat opioid use disorder is less than what 
professionally recognized treatment guidelines generally recommend.  The dosage limits 
for prescription medications set by my plan with respect to medical/surgical benefits are 
not less than the limits such treatment guidelines recommend. Is this permissible under 
MHPAEA? 
No.  Medical management standards that limit or exclude benefits based on medical necessity, 
medical appropriateness, or other factors are NQTLs.9  Plans and issuers may impose dosage 
                                                 
 
8 26 CFR 54.9812-1(c)(4)(ii); 29 CFR 2590.712(c)(4)(ii); 45 CFR 146.136(c)(4)(ii).   
9 See 26 CFR 54.9812-1(c)(4)(ii)(A); 29 CFR 2590.712(c)(4)(ii)(A); 45 CFR 146.136(c)(4)(ii)(A). 
6  limits as a medical management technique with respect to prescription drug coverage under the 
plan.  Even though these medical management techniques may result in numerically expressed 
limitations (such as dosage limits), the techniques are nevertheless NQTLs. The Departments 
regulations require that the processes, strategies, evidentiary standards, or other factors used in 
applying an NQTL to MH/SUD prescription drug benefits (in this case, a dosage limit on 
buprenorphine to treat opioid use disorder) must be comparable to, and applied no more 
stringently than, the processes, strategies, evidentiary standards, or other factors used in applying 
dosage limits to prescription drugs to treat medical/surgical conditions.  If the plan follows the 
dosage recommendations in professionally recognized treatment guidelines to set dosage limits 
for prescription drugs in its formulary to treat medical/surgical conditions, it must also follow 
comparable treatment guidelines, and apply them no more stringently, in setting dosage limits for 
prescription drugs, including buprenorphine, to treat MH/SUD conditions. 
The Departments are aware that, as an alternative to following professionally recognized 
treatment guidelines, many plans and issuers use Pharmacy and Therapeutics (P&T) committees 
to decide how to cover prescription drugs and evaluate whether to follow or deviate from 
professionally recognized treatment guidelines for setting dosage limits. Although the use of 
P&T committees to inform dosage limits for prescription drugs in this manner does not per se 
violate MHPAEA, these processes must comply with MHPAEAs NQTL standard in practice.  
For example, if a plan or issuer deviates from nationally-recognized treatment guidelines for 
buprenorphine/naloxone to treat opioid use disorder based on P&T committee recommendations 
or reports, but does not deviate from such guidelines with respect to covering prescription drugs 
to treat medical surgical benefits based on the recommendations of the P&T committee, then this 
deviation should be evaluated for compliance with MHPAEAs NQTL requirements.  For 
instance, the plan or issuer should determine (1) whether the expertise of the members of the 
P&T committee in MH/SUD conditions is comparable to their expertise in medical/surgical 
conditions (e.g., if a plan ensures that certain members of the P&T committee are board certified 
in the area of medicine that will prescribe the treatment or drug in question, the plan must impose 
this requirement comparably for benefits for both medical/surgical and MH/SUD treatments), 
and (2) whether the committees evaluation of nationally-recognized treatment guidelines in 
setting dosage limits for medications for both MH/SUD and medical/surgical conditions is 
comparable. 
Q4:  My large group health plan or large group insurance coverage provides benefits for 
prescription drugs to treat both medical/surgical and MH/SUD conditions but contains a 
general exclusion for items and services to treat a specific mental health condition, 
including prescription drugs to treat that condition.  Is this permissible under MHPAEA? 
Yes.  Generally, MHPAEA requires that treatment limitations imposed on MH/SUD benefits 
cannot be more restrictive than treatment limitations that apply to medical/surgical benefits. An 
exclusion of all benefits for a particular condition or disorder, however, is not a treatment 
limitation for purposes of the definition of treatment limitations as set forth in the MHPAEA 
regulations.  The MHPAEA regulations also provide that if a plan or issuer provides benefits for 
a mental health condition or substance use disorder, benefits for that condition or disorder must 
be provided in every classification in which medical/surgical benefits are provided. Because the 
7  plan or coverage does not provide any MH/SUD benefits for that specific mental health 
condition in any classification, this exclusion is permissible under MHPAEA.10 
Q5: My health plan requires step therapy for both medical/surgical and MH/SUD 
inpatient, in-network benefits. The plan requires a participant to have two unsuccessful 
attempts at outpatient treatment in the past 12 months to be eligible for certain inpatient 
in-network SUD benefits.  However, the plan requires only one unsuccessful attempt at 
outpatient treatment in the past 12 months to be eligible for inpatient, in-network 
medical/surgical benefits. Is this permissible under MHPAEA? 
Probably not, as it is unlikely that the plans analysis will support the application of this NQTL.  
Refusing to pay for a higher-cost therapy until it is shown that a lower-cost therapy is not 
effective (commonly known as step therapy protocols or fail-first policies) is an NQTL.11  
The Departments regulations require that the processes, strategies, evidentiary standards, or 
other factors used in applying an NQTL to MH/SUD benefits must be comparable to, and 
applied no more stringently than, the processes, strategies, evidentiary standards, or other factors 
used in applying the NQTL to medical/surgical benefits.  Although the same NQTLstep 
therapyis applied to both MH/SUD benefits and medical/surgical benefits for eligibility for 
inpatient, in-network services, the requirement for two attempts at outpatient treatment to be 
eligible for inpatient, in-network SUD benefits is a more stringent application of the NQTL than 
the requirement for one attempt at outpatient treatment to be eligible for inpatient, in-network 
medical/surgical benefits.  Unless the plan can demonstrate that evidentiary standards or other 
factors were utilized comparably to develop and apply the differing step therapy requirements for 
these MH/SUD and medical/surgical benefits, this NQTL does not comply with MHPAEA. If 
the plan can make that demonstration, the plan should document the factors relied upon to 
support the different step therapy protocols. 
Q6. My health plan documents state that in-network provider reimbursement rates are 
determined based on a variety of factors, including the providers required training, 
licensure, and expertise. For medical/surgical benefits, the difference in reimbursement 
rates for physicians and non-physician practitioners for the same Current Procedural 
Technology (CPT) code12 varies based on a combination of factors such as the nature of the 
service, provider type (including demographics), market dynamics, and market need 
availability (demand). For MH/SUD benefits, the plan states that it varies reimbursement 
rates for non-physician practitioners for the same CPT code based on a combination of 
                                                 
 
10 Note that small group and individual health insurance coverage are generally subject to the requirement to provide 
essential health benefits, and the determination of whether certain benefits must be covered under the requirements 
for essential health benefits depends on the benefits in the applicable States essential health benefits benchmark 
plan.  State law may also impose certain benefit mandates for large group insured coverage. See PHS Act section 
Sec. 2707(a); Patient Protection and Affordable Care Act section ACA Sec. 1302(a). 
11 See 26 CFR 54.9812-1(c)(4)(ii); 29 CFR 2590.712(c)(4)(ii); 45 CFR 146.136(c)(4)(ii). 
12 The CPT is a uniform numeric coding system maintained by the American Medical Association (AMA) 
consisting of descriptive terms and identifying codes that are used primarily to identify medical services and 
procedures furnished by physicians and other health care professionals. See HCPCS - General Information, available 
at https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html.  
8  similar factors; however, despite these terms in the plan, the plan reduces the 
reimbursement rate by the same percentage for every CPT code for an MH/SUD service 
rendered by a non-physician practitioner.  The plan does not do so with respect to 
medical/surgical providers. Is this permissible under MHPAEA? 
No.  While MHPAEA does not require a plan or issuer to pay identical provider reimbursement 
rates for medical/surgical and MH/SUD providers, a plans or issuers standards for admitting a 
provider to participate in a network (including the plans reimbursement rates for providers) is an 
NQTL.  A plan or issuer may impose an NQTL if under the terms of the plan as written and in 
operation, the processes, strategies, evidentiary standards, and other factors used by the plan in 
applying its NQTL with respect to MH/SUD benefits are comparable to, and applied no more 
stringently than, those used in applying the NQTL with respect to medical/surgical benefits in 
the same classification. In other words, the plan or issuer must demonstrate that the methodology 
for developing and applying reimbursement rates under the plan is comparable and applied no 
more stringently for MH/SUD benefits when compared to the methodology for developing and 
applying reimbursement rates for medical/surgical benefits under the plan. 
Here, the plans methodology for developing and applying reimbursement rates, in operation, is 
to reduce reimbursement rates by the same percentage for all non-physician practitioners 
providing MH/SUD services, while varying the reimbursement rate for non-physician 
practitioners providing medical/surgical services only when certain factors (e.g. the nature of the 
service, provider type, market dynamics, and demand) support such variance.  The plan does not 
use a comparable process with respect to reimbursement of non-physician providers of 
medical/surgical and MH/SUD services. Accordingly, the plans use of this NQTL does not 
comply with MHPAEA. 
To comply with MHPAEA, the plan must be able to demonstrate that it follows a comparable 
process in determining payment rates for non-physician providers for both medical/surgical and 
MH/SUD benefits. 
Q7: In setting standards for provider admission to its network, my health plan considers 
the composition of current in-network providers to help ensure the plan has an adequate 
number of providers. With respect to its network of medical/surgical providers, the plan 
sets standards for provider admission in a manner that is calculated to ensure that 
participants and beneficiaries can schedule an appointment with a network provider within 
15 days for non-urgent care, including, where appropriate, by increasing reimbursement 
rates and developing a process for accelerating participation in the network.  The plan does 
not take comparable measures, where appropriate, to attempt to ensure an adequate 
network of MH/SUD providers. Is this permissible under MHPAEA? 
9  No.  Standards for provider admission to participate in a network, including reimbursement rates, 
are an NQTL.13 The Departments regulations require that the processes, strategies, evidentiary 
standards, or other factors used in applying an NQTL to MH/SUD benefits must be comparable 
to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other 
factors used in applying the NQTL to medical/surgical benefits. 
Here, in setting standards for provider admission to the network, the plans process to ensure the 
plan considers network adequacy with respect to providers of medical/surgical services is not 
comparable to its process with respect to providers of MH/SUD services. 
The Departments note that greatly disparate resultsfor example, a network that includes far 
fewer MH/SUD providers than medical/surgical providersare a red flag that a plan or issuer 
may be imposing an impermissible NQTL. Accordingly, further review of the NQTL may be 
required to determine parity compliance.14  MHPAEA does not require a plan or issuer to ensure 
that the numbers of MH/SUD and medical/surgical providers in the plans network are 
comparable, but the plan or issuer must undertake a comparable process and apply comparable 
strategies and evidentiary standards when developing and ensuring an adequate network. In this 
example, because the plans process for setting standards for MH/SUD provider admission to its 
network is not comparable to the process employed with respect to medical/surgical providers, 
the plan does not comply with MHPAEA. 
To comply with MHPAEA, if the plan takes steps to ensure the plan has an adequate number of 
in-network medical/surgical providers, the plan must take comparable steps to ensure an 
adequate number of in-network MH/SUD providers, even if, following those steps, ultimately 
there are disparate numbers of MH/SUD and medical/surgical providers in the plans network. 
Q8: My health plan generally covers medically appropriate treatments. The plan covers 
inpatient, out-of-network treatment outside of a hospital setting for medical/surgical 
conditions if the prescribing physician obtains prior authorization from the plan, the 
facility meets the licensing and certification requirements set by the plan, and the 
treatment is medically appropriate for the individual, based on clinically appropriate 
standards of care.  The plan provides benefits for the treatment of eating disorders but 
                                                 
 
13 As stated in the preamble to the Departments final rules implementing MHPAEA, plan standards such as network 
adequacy (although not specifically enumerated in the illustrative list of NQTLs), must be applied in a manner that 
complies with the regulations. 78 FR 68239, 68246 (Nov. 13, 2013). 
14 For additional red flags, see Warning Signs - Plan or Policy Non-Quantitative Treatment Limitations (NQTLs) 
that Require Additional Analysis to Determine Mental Health Parity Compliance (June 1, 2016), available at: 
https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/mental-health-parity/warning-signs-plan-or-
policy-nqtls-that-require-additional-analysis-to-determine-mhpaea-compliance.pdf and 
https://www.cms.gov/CCIIO/Resources/Regulations-and-
Guidance/Downloads/MHAPEAChecklistWarningSigns.pdf. 
10  excludes all inpatient, out-of-network treatment outside a hospital setting for eating 
disorders, including non-hospital residential treatment (which it regards as an inpatient 
benefit).  Is this permissible under MHPAEA? 
No.  The Departments regulations implementing MHPAEA define mental health benefits as 
benefits with respect to items or services for mental health conditions, as defined under the terms 
of the plan or health insurance coverage and in accordance with applicable Federal and State law. 
Section 13007 of the Cures Act clarified that if a group health plan or health insurance issuer 
offering group or individual health insurance coverage provides coverage for eating disorder 
benefits, including non-hospital residential treatment, those benefits must be offered consistent 
with the requirements of MHPAEA.  Accordingly, the Departments have clarified that eating 
disorders are mental health conditions and, therefore, treatment of an eating disorder is a mental 
health benefit within the meaning of that term as defined by MHPAEA.15 
Plan or coverage restrictions based on facility type are NQTLs under the MHPAEA final 
regulations.16  A plan or issuer may impose an NQTL if, under the terms of the plan as written 
and in operation, the processes, strategies, evidentiary standards, and other factors used by the 
plan or issuer in applying its exclusion with respect to MH/SUD benefits are comparable to and 
applied no more stringently than, those used in applying the NQTL to medical/surgical benefits 
in the same classification. In evaluating whether an exclusion of an intermediate level of care, 
including non-hospital residential treatment complies with MHPAEA, it must be determined if 
the intermediate level of care is assigned to the six benefit classifications in the same way for 
both medical/surgical and MH/SUD benefits.17  If so, then the basis for the exclusion (in this 
case, non-hospital residential treatment) in the classification must be reviewed to determine if the 
processes, strategies, evidentiary standards, and other factors used to apply the exclusion of 
MH/SUD benefits are comparable to and applied no more stringently than the processes, 
strategies, evidentiary standards, and other factors used in applying the NQTL to 
medical/surgical benefits in the same classification. 
If a plan or issuer can articulate comparable and no more stringently applied processes, 
strategies, evidentiary standards, or other factors to exclude non-hospital residential treatment for 
MH/SUD benefits in certain circumstances, the plan or issuer may be able to demonstrate that 
the exclusion is consistent with the regulations under MHPAEA. However, in this example, the 
plan covers inpatient, out-of-network treatment outside a hospital for medical/surgical conditions 
                                                 
 
15 See Frequently Asked Questions about Mental Health and Substance Use Disorder Parity Implementation and the 
21st Century Cures Act Part 38, available at 
https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-38.pdf and 
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQ-Part-38.pdf. 
16 26 CFR 54.9812-1(c)(4)(ii), 29 CFR 2590.712(c)(4)(ii), and 45 CFR 146.136(c)(4)(ii). 
17 See 26 CFR 54.9812-1(c)(2)(ii)(A), 29 CFR 2590.712(c)(2)(ii)(A), and 45 CFR 146.136(c)(2)(ii)(A).  See also the 
preamble to the Departments final rules implementing MHPAEA, which states that if a plan or issuer classifies care 
in skilled nursing facilities or rehabilitation hospitals as inpatient benefits, then the plan or issuer must likewise treat 
any covered care in residential treatment facilities for MH/SUD services as an inpatient benefit. In addition, if a plan 
or issuer treats home health care as an outpatient benefit, then any covered intensive outpatient MH/SUD services 
and partial hospitalization must be considered outpatient benefits as well. 78 FR 68240, 68247 (Nov. 13, 2013). 
11  so long as a prescribing physician obtains prior authorization from the plan, the treatment is 
medically appropriate for the individual, and the facility meets the licensing and certification 
requirements set by the plan, while the plan unequivocally excludes all inpatient, out-of-network 
treatment outside a hospital (in this case, non-hospital residential treatment) for eating disorders.  
This restriction on non-hospital residential treatment for eating disorders is not comparable to the 
plans coverage restrictions for inpatient treatment outside a hospital for medical/surgical 
conditions, which are less stringent. This exclusion does not comply with MHPAEA. 
A plan or issuer may rely on one or more factors to develop and apply an NQTL, provided the 
factors are comparable and no more stringently applied to MH/SUD benefits as compared to 
medical/surgical benefits (in this case, both medical appropriateness of the service, as well as the 
credentials of the facility). Such factors can be a mix of statistical, clinical or other factors, such 
as high incidence of fraud with respect to services in a particular classification.18 The plan or 
issuer should document any factors relied upon in developing and applying this NQTL. 
Disclosures with Respect to MH/SUD Benefits 
The MHPAEA final regulations provide express disclosure requirements. Specifically, the 
criteria for medical necessity determinations with respect to MH/SUD benefits must be made 
available by the plan administrator or the health insurance issuer to any current or potential 
participant, beneficiary, or contracting provider upon request.19 In addition, under MHPAEA, the 
reason for any denial of reimbursement or payment for services with respect to MH/SUD 
benefits in the case of any participant or beneficiary must be made available to the participant or 
beneficiary.20 
The Departments also explained in the preamble to the final regulations that, in addition to these 
specific disclosure obligations under MHPAEA, ERISAs general disclosure obligation in 
section 104(b) and the accompanying disclosure regulation at 29 CFR 2520.104b-1 provide that, 
for plans subject to ERISA, instruments under which the plan is established or operated must 
generally be furnished to plan participants within 30 days of request. A document that specifies 
procedures, formulas, methodologies, or schedules that are applied in determining or calculating 
a participants benefit under the plan constitutes an instrument under which the plan is 
established or operated.21  Instruments under which the plan is established or operated include 
documents with information on medical necessity criteria for both medical/surgical benefits and 
MH/SUD benefits, as well as the processes, strategies, evidentiary standards, and other factors 
                                                 
 
18 See 26 CFR 54.9812-1(c)(4)(iii), Example 8; 29 CFR 2590.712(c)(4)(iii), Example 8, and 45 CFR 
146.136(c)(4)(iii), Example 8. 
19 26 CFR 54.9812-1(d)(1), 29 CFR 2590.712(d)(1), 45 CFR 146.136(d)(1) and 147.160. 
20 26 CFR 54.9812-1(d)(2), 29 CFR 2590.712(d)(2), 45 CFR 146.136(d)(2) and 147.160. 
21 See Advisory Opinion 96-14A, available at https://www.dol.gov/agencies/ebsa/employers-and-
advisers/guidance/advisory-opinions. 
12  used to apply an NQTL with respect to medical/surgical benefits and MH/SUD benefits under 
the plan. In addition, 29 CFR 2560.503-1, 26 CFR 54.9815-2719, 29 CFR 2590.715-2719 and 45 
CFR 147.136 set forth rules regarding claims and appeals, including the right of claimants (or 
their authorized representative) upon appeal of an adverse benefit determination (or a final 
internal adverse benefit determination) to be provided upon request and free of charge, 
reasonable access to and copies of all documents, records, and other information relevant to the 
claimants claim for benefits. 22 This includes documents with information on medical necessity 
criteria for both medical/surgical benefits and MH/SUD benefits, as well as documents reflecting 
the processes, strategies, evidentiary standards, and other factors used to apply an NQTL with 
respect to medical/surgical benefits and MH/SUD benefits under the plan. 
Contemporaneous with the issuance of the MHPAEA final regulations, the Departments 
published FAQs23 addressing a group health plans disclosure obligations under MHPAEA and 
ERISA generally, as well as the specific information a participant is entitled to receive when a 
claim for MH/SUD benefits has been denied. In addition to reiterating that instruments under 
which the plan is established or operated under ERISA section 104 includes documents with 
information on medical necessity criteria for both medical/surgical and MH/SUD benefits, as 
well as the processes, strategies, evidentiary standards, and other factors used to apply an NQTL, 
the FAQs noted that other provisions of Federal law require such disclosures. 
On October 27, 2016, the Departments issued Affordable Care Act Implementation FAQs Part 
34, which, among other things, solicited feedback regarding disclosures with respect to MH/SUD 
benefits under MHPAEA and other laws. In the FAQs, the Departments indicated that they had 
received questions and suggestions regarding disclosures with respect to NQTLs. This feedback 
included requests for model forms that group health plan participants, beneficiaries, covered 
individuals in the individual market, or persons acting on their behalf could use to request 
relevant disclosures. The Departments initially proposed a model form on June 16, 2017 and 
solicited comments. After reviewing the comments, the Departments proposed a revised model 
form on April 23, 2018 and again solicited comments. The Departments are finalizing this model 
disclosure request form, with some clarifications in response to comments.  Use of the form by 
participants, beneficiaries, and enrollees is optional and is meant to facilitate the ability of 
                                                 
 
22 A document, record, or other information is considered relevant for a group health plan under 29 CFR 
2560.503-1(m)(8) if it (i) was relied upon in making the benefit determination; (ii) was submitted, considered, or 
generated in the course of making the benefit determination, without regard to whether such document, record, or 
other information was relied upon in making the benefit determination; (iii) demonstrates compliance with the 
administrative processes and safeguards required to ensure and verify that claims are decided in accordance with 
governing plan documents and consistently with similar claims; or (iv) constitutes a statement of plan policy or 
guidance concerning the denied treatment option or benefit for the claimants diagnosis, without regard to whether 
such advice or statement was relied upon in making the benefit determination. 
23 See FAQs about Affordable Care Act Implementation (Part XVII) and Mental Health Parity  
Implementation, available at https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-
center/faqs/aca-part-xvii.pdf and https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-
FAQs/aca_implementation_faqs17.html. 
 
13  covered individuals to request information disclosure in certain circumstances.  The model form 
is set forth at the end of these FAQs. 
The following FAQs provide examples of how certain provisions of Federal law may require 
disclosures relevant to MH/SUD benefits. 
Q9: I wish to request information from my ERISA-covered group health plan regarding 
limitations that may affect my access to MH/SUD benefits. Do the Departments have any 
materials that may assist me? 
Under ERISA, plans are required to provide summary plan descriptions (SPDs) that describe, in 
terms understandable to the average plan participant, the rights, benefits, and responsibilities of 
participants and beneficiaries. Plans are also required to provide a Summary of Benefits and 
Coverage (SBC) that includes, among other elements, a description of the coverage; the 
exceptions, reductions, and limitations of the coverage and the cost-sharing provisions of the 
coverage. The Departments encourage participants and beneficiaries to first consult their SBC, as 
well as their SPD, for information on how their plan covers MH/SUD benefits. If you do not 
have an SPD or SBC, consider requesting them.  Generally, the plan is required to give 
participants and beneficiaries copies of these documents on request. 
The Departments also developed a model form that individuals, or their authorized 
representatives maybut are not required touse to request information that may affect their 
MH/SUD benefits. This model form can be used for general requests for information regarding 
MH/SUD benefits and treatment limitations, such as a request for the relevant portions of the 
SPD or plan document. This model form can also be used to obtain documentation after an 
adverse benefit determination involving MH/SUD benefits to support an appeal. Furthermore, 
plans and issuers may find that making this model disclosure form available to their participants 
or enrollees may help clarify and streamline requests for information. Use of the form is optional 
for participants, and plans and issuers may use their own disclosure forms to help facilitate 
disclosure requests. The model form is set forth at the end of these FAQs. 
Q10: My ERISA-covered group health plan utilizes a provider network and provides a 
provider directory with its SPD.  The entire directory is out of date and inaccurate.  Is this 
permissible? 
No.  Under 29 CFR 2520.102-3(j)(3) of the DOLs regulations, if an ERISA-covered plan 
utilizes a network, its SPD must provide a general description of the provider network, as well as 
the composition of the provider network.  The list of providers may be distributed as a separate 
document that accompanies the plans SPD if it is furnished automatically and without charge 
and the SPD contains a statement to that effect.  The list of providers, whether set forth in the 
SPD, or separately, must be up-to-date, accurate, and complete (using reasonable efforts). 
Qualified Health Plan (QHP) issuers are also obligated to comply with 45 CFR 156.230(b)(2) of 
HHSs regulations that requires the issuer to publish an up-to-date, accurate, and complete 
provider directory, including information on which providers are accepting new patients, and the 
providers location, contact information, specialty, medical group, and any institutional 
14  affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the 
State, the Health Insurance Marketplace, HHS, and the Office of Personnel Management (OPM). 
Q11:  Are ERISA-covered plans and issuers that utilize provider networks permitted to 
provide a hyperlink or URL address in enrollment and plan summary materials for a 
provider directory where information related to network providers, including MH/SUD 
providers, can be found? 
Yes. ERISA-covered plans must provide an SPD that describes provisions related to the use of 
network providers, and the composition of the provider network, under ERISA section 102 and 
DOLs implementing regulations.  Such information may be provided as a separate document 
and, in many circumstances, may be provided electronically (for instance in a hyperlink or URL 
address).24 
Furthermore, under PHS Act section 2715 and its implementing regulations, for group health 
plans and health insurance issuers offering group or individual health insurance coverage that 
maintain one or more networks of providers, the plan or issuer must provide a SBC that includes 
an Internet address (or similar contact information) for obtaining a list of network providers.25 
Finally, as stated in Q&A-10, QHP issuers must make their provider directories available online. 
For plan years beginning on or after January 1, 2016, a QHP issuer must publish an up-to-date, 
accurate, and complete provider directory, including information on which providers are 
accepting new patients, and the providers location, contact information, specialty, medical 
group, and any institutional affiliations, in a manner that is easily accessible to plan enrollees, 
prospective enrollees, the State, the Exchange, HHS, and OPM.26
                                                 
 
24 29 CFR 2520.104b-1(c). 
25 26 CFR 54.9815-2715(a)(2)(K), 29 CFR 2590.715-2715(a)(2)(K), 45 CFR 147.200(a)(2)(K). 
26 45 CFR 156.156.230(b)(2). 
15   
MODEL DISCLOSURE FORM 
FORM TO REQUEST DOCUMENTATION FROM AN EMPLOYER-SPONSORED 
HEALTH PLAN OR A GROUP OR INDIVIDUAL MARKET INSURER CONCERNING 
TREATMENT LIMITATIONS 
Background: This is a tool to help you request information from your employer-sponsored health 
plan or your group or individual market insurer regarding treatment 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, like your plans preauthorization 
policies for both medical/surgical and mental health treatment.  
  Specific information about why benefits were denied. For example, you can ask about 
the criteria for failure to show medical necessity that your health insurance company 
may have used to deny your claim.  
Your plan or insurer is required by law to provide you this information in certain instances. In 
some cases, a request can result in more information than you may want. Talk to your plan or 
insurer about what documents you wish to request, and, if you prefer, how you can receive the 
documents electronically. 
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.  This generally means that 
financial requirements and treatment limitations applied to mental health or substance use 
disorder benefits cannot be more restrictive than the financial requirements and treatment 
limitations applied to medical and surgical benefits.  The types of limits covered by parity 
protections include: 
  Financial requirementssuch as deductibles, copayments, coinsurance, and out-of-
pocket limits; and 
  Treatment limitationssuch as limits on the number of days or visits covered, or other 
limits on the scope or duration of treatment (for example, being required to get prior 
authorization). 
If you, a family member, or someone you are helping obtains health coverage through a private 
employer health plan, federal law requires the plan to provide certain plan documents about your 
or their benefits, including coverage limitations on those benefits, on request.  For example, you 
may want to obtain documentation as to why your health plan is requiring pre-authorization for 
visits to a therapist before it will cover the visits.  Generally, private employer plans must 
provide the documents within thirty (30) calendar days of the plans receipt of your request. 
Contact your health plan or health insurance company directly to submit your request.    
This form is designed to help you request information from your plan about treatment 
limitations.  Many common types of treatment limits are listed on this form.  If the type of 
treatment limitations being imposed by your plan does not appear on the list, you may insert a 
16   
description of the treatment limitation about which you would like more information under 
Other.   
Instructions:  Complete the attached form to request general information from your plan or 
insurer about treatment limitations or specific information about why your mental health or 
substance use disorder benefits were denied.  This information may help you appeal a claim 
denial, but you must separately initiate the plans general review and appeals process if you want 
to appeal the claim denial with your plan or insurer.  You do not have to use this form to request 
information from your plan. Consult your summary plan description (SPD) or certificate of 
coverage to see how to request information from the plan, or how to appeal a denied claim.  
If you are helping someone request information about his/her health coverage, a plan or insurer 
may require you to submit, with your request for information, additional documentation signed 
by the person you are helping (if you have not already done so).  
If you have any questions about this form and you are enrolled in a private employer health plan, 
you may visit the Employee Benefits Security Administrations (EBSAs) website at 
www.dol.gov/ebsa for answers to common questions about private employer health plans. You 
may also contact EBSA electronically at www.askebsa.dol.gov or call toll free 1-866-444-3272.  
You can also use this form if you are enrolled in coverage that is not through a private employer 
health planfor example, if you have individual health coverage or coverage sponsored by a 
public sector employer, like a city or state government.  You may contact the Centers for 
Medicare & Medicaid Services (CMS) at phig@cms.hhs.gov or 1-877-267-2323 ext. 61565 for 
questions about your individual health coverage or public sector health plan. 
   
17   
PRA Disclosure Statement 
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a 
collection of information unless it displays a valid OMB control number.  The valid OMB 
control number for this information collection is 1210-0138.  The time required to complete this 
information collection is estimated to average 5 minutes per response, including the time to 
review instructions, search existing data resources, gather the data needed, and complete and 
review the information collection.  If you have comments concerning the accuracy of the time 
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Labor, 
Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA 
Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or 
email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0138.
18   
Date: _____________________ 
Mental Health and Substance Use Disorder Parity Disclosure Request 
. 
NOTE: This disclosure request form is NOT designed to initiate a formal claim for 
benefits or an appeal of a denied claim; however, the information obtained through this 
 
form may help you appeal a medical claim denial with respect to your mental health 
and substance use disorder benefits.  Submitting this form is voluntary and does NOT 
 
replace your health plans claims or appeals process. 
 
To: ______________________________ [Insert name of the health plan or issuer] 
(If you are a provider or another representative who is authorized to request information for 
the individual enrolled in the plan, provide the information below.) 
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. 
(Complete this section if youre requesting general information about treatment limitations.) 
General Information Request 
  I am requesting information concerning the plans limitations related to coverage for: 
  Mental health and substance use disorder benefits, generally.  
  The following specific treatment for my mental health condition or substance use 
disorder: ____________________________. 
(Complete this section if youre requesting specific information about limitations that led to a 
denial of benefits.) 
Claim/Denial Information Request  
  I was notified on __________[Insert date of denial] that a claim for coverage of 
treatment for_________________ [Insert mental health condition or substance use 
disorder] was, or may be, denied or restricted for the following reason[s] shown 
immediately below: 
19   
(Based on your understanding of the denial of, limitation on, or reduction in coverage, check 
all that apply) 
  I was advised that the treatment was not medically necessary. 
o
  I was advised that the treatment was experimental or investigative. 
o
  The plan requires authorization before it will cover the treatment. 
o
  The plan requires ongoing authorizations before it will cover my continued 
o
treatment. 
  The plan is requiring me to try a different treatment before authorizing the 
o
treatment that my doctor or therapist recommends. 
  The plan will not authorize any more treatments based on the fact that I failed to 
o
complete a prior course of treatment. 
  The plans prescription drug formulary does not cover the medication my doctor 
o
is prescribing. 
  My plan covers my mental health or substance use disorder treatment, but does 
o
not have any reasonably accessible in-network providers for that treatment. 
  I am not sure whether my plans calculation of payment for out-of-network 
o
services, such as its methods for determining usual, customary and reasonable 
charges, complies with parity protections. 
  Other: (Specify basis for denial of, limitation on, or reduction in coverage): 
o
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________ 
Because my health coverage is subject to the parity protections, financial requirements or 
treatment limitations cannot be applied to mental health or substance use disorder benefits unless 
those limits are comparable to financial requirements or treatment limitations applied to medical 
and surgical benefits.  Therefore, for the limitations or terms of the benefit plan specified above, 
within thirty (30) calendar days from the date of receipt of this request, I request that the 
plan: 
  1.  Provide the specific plan language regarding the limitation(s) and identify the 
medical/surgical and mental health or substance use disorder benefits to which it applies 
in the relevant benefit classification described in the regulations under the Mental Health 
Parity and Addiction Equity Act;  
  2.  Identify the factors used in the development of the limitation(s) (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); 
20   
  3. Identify the sources (including any processes, strategies, or evidentiary standards) used 
to evaluate the factors identified above.  Examples of evidentiary standards 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 that a treatment is not experimental or 
investigative; 
  4.  Identify the methods and analysis used in the development of the limitation(s); and  
  5.  Provide any evidence and documentation to establish that the limitation(s) is applied 
no more stringently, as written and in operation, to mental health and substance use 
disorder benefits than to medical and surgical benefits. 
__________________________________________________ 
Printed Name of Individual Enrolled in the Plan or his or her Authorized Representative 
__________________________________________________ 
Signature of Individual Enrolled in the Plan or his or her Authorized Representative 
__________________________________________________ 
Member Number (number assigned to the enrolled individual by the Plan) 
 
Claim Number (if seeking information regarding a specific claim) 
__________________________________________________ 
Address 
__________________________________________________ 
Date 
__________________________________________________ 
E-mail address (if email is a preferred method of contact) 
 
21