March 7, 2025 • 21 mins
Based on AHLA's annual Health Law Connections article, this special series brings together thought leaders from across the health law field to discuss the top ten issues of 2025. In the seventh episode, Christianna Finnern, Shareholder, Winthrop & Weinstine PA, speaks with Noreen Vergara, Partner, Husch Blackwell LLP, about the Mental Health Parity and Addiction Equity Act (MHPAEA) and its requirements. They discuss some of the changes in the final rule, whether the new administration or the Loper Bright Supreme Court case will affect compliance and enforcement of MHPAEA, and how MHPAEA impacts average health care consumers and those who don’t work in the benefits and managed care space. From AHLA’s Behavioral Health Practice Group.
Watch the conversation here.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Speaker 2 (00:04):
A HLA is pleased to present this special series
highlighting the top 10 healthlaw issues of 2025, where we
bring together thought leadersfrom across the health law
field to discuss the majortrends and developments of the
year. To stay updated on allthe major health law news,
subscribe to ALA's New HealthLaw Daily podcast. Available
exclusively for premiummembers@americanhealthlaw.org
(00:27):
slash daily podcast .
Speaker 3 (00:35):
Hello, everybody. My name is Christiana Finner , and
I'm an attorney at the law firmof Win and Weinstein in
Minneapolis, Minnesota. Ipractice in my firm's
healthcare regulatory group,and I am a , uh, member for
many years of the AmericanHealth Law Association
Behavioral Health PracticeGroup. I am currently the vice
(00:56):
chair for member engagement.
Um, I'm very pleased to be heretoday , um, on episode number
seven of our top 10 , um,issues in health Law 2025. Um,
joining me today is Noreen Ra ,who is a partner at Hush
Blackwell, and she is theco-author of an article , um,
(01:19):
entitled The Impact of the 2024Mental Health Parity and
Addiction Equity Act, finalRule in 2025, focused on
access. And , um, Noreen isgoing to answer some questions
for us today about , um, thearticle. And Noreen, I will
turn it over to you tointroduce yourself.
Speaker 4 (01:38):
Thank you so much, Christiana. It's, it's very
nice to be here. Thank you forinviting me to talk about a
topic that I care very muchabout and have worked in for
the, the better part of, of twodecades. Um, I'm a partner at
Hush Blackwell in thehealthcare regulatory practice
group and specialize in, inbehavioral health, but also in
(02:01):
healthcare reimbursement. Andthat's, that's where mental
health parity sits. Uh , priorto joining Hush , I worked
in-house at the NationalAssociation of Insurance
Commissioners where I got a, aheavy , a dose of Affordable
Care Act regulation. Uh, then Iwas general counsel for a
(02:22):
behavioral healthcare managedcare company for about eight
years, and now I'm, now I'm atHush , uh, working on, on the
same, same laws, different, Iguess different aspect,
different side,
Speaker 3 (02:37):
Different lens. Very good. Um, well, you obviously
have a lot of background inbehavioral health. Parody is a
huge thing. Um, and, you know ,um, the , these were very long
awaited revisions. What areyour thoughts generally on the
2024 final rule and , um, itsrequirements?
Speaker 4 (02:57):
So my overall thoughts are the 20 20 24 final
rule. Uh, basically there,there's, in my mind a , a vibe
shift. Uh, the departments ofLabor , uh, health and Human
Services and the TreasuryDepartment have indicated
through this rule that they areready to enforce. Um, and
(03:18):
they've been getting that kindawarming up towards that for,
for a long time. Um, just as,as background , uh, mia , which
I will probably frequently sayMIA or parody interchangeably,
but what I'm really referringto is the Federal Mental Health
Parity and Addiction EquityAct. And then we're talking
(03:41):
today about the 2024 finalrule, which builds on a 2013
final rule. So there's, there'sover a decade or close to a
decade, well, I guess over adecade, if you go back to 2008,
when, when this act was enactedof increasing enforcement,
(04:01):
increasing , um, I guessattention paid by the, the
federal regulators to howbehavioral health benefits and
are treated comparably tomedical surgical benefits , um,
MIAA is regulated by threedifferent agencies. So when I
(04:24):
say the departments, I'mreferring to a trifecta of the
departments of labor , um,which regulates fully insured
plans , um, or self-funded,sorry, not fully insured,
self-funded plans. My mistake ,uh, department of Health and
Human Services, which regulatesfully insured plans. And then
(04:45):
the Treasury Department, whichregulates church plans. So
those three together are thedepartments. And in this 2024
final rule, they've indicatedthe rate ready to enforce. Um,
they've built on the 2013 ruleyears of subregulatory guidance
and red flag documents issuedto the states. They've issued
(05:07):
reports to Congress, they'veexpressed the need to have
additional authority, whichthey received in the
Consolidated AppropriationsAct. So from a enforcement and,
and what the departments need ,um, they're ready to go. That
being said, the other takeawaythat I have from this role is
that the departments are stillstruggling with , with how to
(05:30):
comply with this lawthemselves. In , in my review,
in my estimation , um, they'restill changing definitions.
They are increasing , uh, andadding new concepts. Um, and
they are making dramaticchanges with, you know, in
regulation to how benefits willbe administered, not just for
(05:57):
mental health and, andsubstance use disorder
benefits, but all benefits,medical, surgical, and
behavioral health. So I reallythink this is a significant
rule. Um, it's, it's a lot gota lot in there. It's very
dense, but it is, in my view,the final step to , um, the
(06:18):
departments and particularlythe Federal Department of Labor
completing audits, finding, youknow, acts of non-compliance
and then sending letters tomembers and allowing ERISA
suits to proceed forward. Andthat's been the kind of
boogeyman lurking in thecorner. And it, it seems, it
(06:39):
seems pretty close right now.
Speaker 3 (06:42):
Good. Well, this is , um, you know, very gonna be
very interesting times with ,um, the final rule and, and
how, kind of how it intersectswith the new administration.
Tell us , um, tell us aboutsome of the changes in the 2024
final rule.
Speaker 4 (06:56):
Okay, so there are many , uh, one kind of major
underlying change is kind ofthe definition of mental health
benefits prior to this rule.
Um, and historically healthplans have had the discretion
to categorize their benefits inthe medical, surgical or
(07:16):
behavioral, and this is, theymake this decision through a
variety of factors. Um, asignificant one is what is the
nature of the condition beingtreated, but it's, it's not the
only factor as to why a benefitor procedure , um, gets , uh,
(07:38):
classified as one or the other.
In the 2024 final rule onechange is that the departments
specify , um, that the plansmust use the current , uh, DSM,
and that is a, a manual , um,that designates or lists out
(08:03):
mental health and, andbehavioral health conditions.
It, it isn't a benefitguidebook. It, it exists. I
think we're in , uh, well,we've had several additions of
it, but it is not intended, itnever has been intended to ,
uh, impact benefits. However,now the federal, the 2024 rule
(08:26):
says, look at the DSM, and ifthe treatment or procedure is
used to treat a mental healthcondition, then it is a mental
health benefit. That soundsvery, you know, small and just
a minor shift of wording. Andit is, but it's, it's a
significant change, especiallyfor those treatments and , and
(08:49):
procedures and services thatcan have both a medical
surgical and a behavioralhealth use. For example , um,
speech therapy, occupationaltherapy for , uh, under this
new rule will be treateddifferently depending on
whether this , the patient isreceiving speech therapy and
(09:11):
occupational therapy or autism,a behavioral health condition
in the DSM or , um, you know,an issue with the, a physical
issue with the, the mouth or ,um, you know, tongue a a purely
medical condition. Those accessto treatment now is, is, has to
(09:34):
follow the condition being ,um, treated, and that is a very
significant change. Anotherchange in this rule is the
requirement for plans, healthplans to proactively take
action, reasonable action, butstill action to address , um,
(09:55):
negative or instances ofinappropriate or lack of access
to parity to behavioral healthbenefits. Um, this is shown in
their dis in the department'sdiscussion of licensure types
and their network. Um, whereasprior to the 2024 rule plans
(10:15):
had to track and trend and ,and review what was happening,
but there was no affirmativerequirement to change their
network to add more licensuretypes, for example, for
behavioral health benefits orchange credentialing standards
to make it easier forbehavioral health licensure
(10:39):
licensed clinicians to get inversus medical surgical. That
is a wholly new , uh, balancingtest and , and way to look at
it .
Speaker 3 (10:49):
Noreen, switching kind of gears to , um, what we
kind of , uh, previewed , um,earlier was, you know, the
impact of administrationchanges , um, on mia . Do you
think that the Department ofGovernment Efficiency Doge or
the Supreme Court case , LoperBright , which recently came
(11:09):
down, will have an effect onMIA compliance and or
enforcement?
Speaker 4 (11:16):
Well, this is something I've been thinking a
lot about, and the short answerI think is yes , um, it will
have an effect. Um, so LoperBright came out last fall and
around the same time that theinterim final rule for the 2024
final rule was, was out andbeing reviewed. I'm not a LOPA
(11:37):
bright expert and or work inthis area. However , um, you
know , I do follow it andunderstand that, you know, the
Supreme Court overturned theChevron doctrine in that case,
which allowed deference toexecutive agencies, broadly
speaking. Um, the reason Ithink that Loper Bright may
(12:01):
have an impact or will have animpact if reviewed is because
meia from its outset , uh,going back to the 2013
regulation, and, and it's nodifferent in this 2024
regulation meia , as we know,it is largely a creature of
regulation as opposed tostatute. Um , meia itself is,
(12:24):
is pretty short , um, andentire concepts , um, for
example, the non-quantitativetreatment limitation or NQTL,
which is of much, much focus inthe 2024 Reg NQTL is, is a
concept that appeared in the2013 final regulation. It , it
(12:45):
doesn't go back to the, to thelaw. So , um, or actually even
the 2013 interim reg , finalreg. So given the structure of
Meia and what is happening at afederal level with , um, the
change in administration, I dothink if reviewed laws like MIA
(13:10):
are vulnerable because most ofthe teeth are, are built into
the reg as opposed to the lawitself. Um, and, and mia we've
had a, a decade of this , um,regulatory guidance and
sub-regulatory guidance, andthe departments are ready to
move on that regulatoryguidance. Um, a change or a
(13:35):
shift in how courts interpretthat regulatory guidance of
challenge, I think could ,could really have a, a very
significant impact on mia . Um,similarly with Doge, or maybe
not similarly, but you know, Ithink Doge may very well have
an impact. Um, MIA is regulatedor enforced by three agencies
(13:59):
working together, theDepartment of Labor, department
of Health and Human Servicesand Treasury. Um, we know that
treasury is undergoing quite a,a , a review, and we don't know
yet whether there will be achange to any of their scope
going forward. Treasury isresponsible for reviewing or
(14:21):
enforcing and regulating churchplans in Mepe , which is not
something intuitively that youwould think the Treasury
Department would have authorityover. Um, similarly, we don't
know what will happen withHealth and Human Services , um,
or the Department of Labor andits ability to enforce areas
(14:41):
of, of law that weretraditionally , um, reserved to
the states. The way that the ,um, the regulatory framework or
the enforcement structure inMIAA is set up is that in , in
, in the 24 Reg and, and reallywith the Consolidated
Appropriations Act, theDepartment of Labor has the
(15:04):
ability to kind of step out infront and conduct the audits
and, and do the work, and thenthey share their findings with
other agencies in the states.
However, this is, this is a , abit of a flip from how re
insurance has been regulatedfor, for 150 years, which it's
traditionally been a functionof state insurance regulation
(15:25):
that changed with theAffordable Care Act. And then
now we've, we've got federalenforcement in a very big way.
Um, we don't know the extent ofthat, whether that framework,
what that's going to look like, um, after dos. And I think
that's , uh, I think that'sdefinitely something to, to pay
(15:47):
close attention to.
Speaker 3 (15:50):
Along those lines, Mia isn't a well-known law ,
um, which, you know, is , um,somewhat regrettable. Um, how
would it impact an everydayconsumer of healthcare or
someone that doesn't workaround benefits and managed
care?
Speaker 4 (16:08):
Absolutely. Um, people aren't, most people
don't even know what Meia is.
They're not inclined to thinkabout behavioral health
benefits unless they need theservice. And when you need the
service, you then you need it.
Um, however, under theAffordable Care Act , uh, you
know, broadly speaking, when ahealth plan offers mental
(16:30):
health and substance usedisorder benefits or
collectively behavioral healthbenefits, when they offer those
and they sell those, they needto provide those at parity. Um,
and then that's where all thetesting comes in. And , and you
get the, the complicated , um,definitional framework. The
testing requirements for parityapply across all benefits. It's
(16:51):
not just behavioral, it's a ,um, you have to look at what
the health plan is doing on themedical side in order to
determine whether what the planis doing on the behavioral side
is compliant or not. So thisrequires it's kind of forced
integration. Um, so thatproduces that kind of forced
(17:13):
integration. Plus, you know,compliance is really getting
ready to start pending Loperand Doge , um, that can present
some odd decisions and, andappear odd to the consumer. As
an example of some things thatmight change that you wouldn't
think of , um, because of, ofMeia is prior authorization ,
(17:37):
um, several years ago , um,maybe not even that far, you
know, not far in the past priorauthorization on medical
benefits going into inpatientin the hospital was pretty
rare. Um, however, now it'sback and we're finding health
plans that are requiring priorauthorization across all
benefits, every inpatient stay.
(17:57):
You must get a prior authbefore you go in. So why are
those things back? Well , Idon't have a , a crystal ball
or have any insightinformation, but parity
requires, you know,comparability and it also
prohibits a health plan fromtreating or , um, imposing
(18:20):
stricter and more stringentrequirements on the behavioral
health side. Then they do themedical. So in the prior
authorization situation, priorauthorization was a pretty
common , um, N-Q-T-L-I guess tobe used on the behavioral
health side, getting anauthorization before you go
inpatient into a , uh,behavioral health facility, not
(18:43):
so much on the medical side,but parity one, at least
intuitive outcome that thatappears to be playing out. Um,
you can't have that, you can'thave prior authorization on
behavioral and not a medicalsurgical. So in one sense,
maybe the departments had hopedthat prior authorization would
(19:06):
reduce and, and would disappearacross the board because you
don't do it on medical. Whywould you do it on behavioral?
That makes a lot of sense, andmaybe that does happen for some
plans, but an alternate way ,um, to be compliant is to
require prior authorization foreverything because then you're
(19:26):
not, you know, reducing or morestringent on behavioral health.
Everybody has the same high barto get inpatient. So those are
some of the , um, the ways thatMIA compliance and the , the
decisions that plans are makingbehind the scenes , um, can
(19:48):
impact those who, who aren'tpaying attention to behavioral
health benefits at all.
Speaker 3 (19:55):
Good. Well, this has been , um, very informative.
I've really enjoyed getting thechance to speak with you about
the changes .
Speaker 4 (20:03):
Thank
Speaker 3 (20:03):
You . The final rule, and if you all in the
audience have also enjoyed thisvery much, encourage you to get
involved with the behavioralhealth practice group within
the A HLA. It is a fantasticresource for , um, articles
like this and a great way toget to know other people who
practice in the behavioralhealth space. Um, and Noreen,
(20:27):
any final , uh, thoughts or orwords from you on , uh, the
final rule and , um, AIA goingforward?
Speaker 4 (20:35):
No, I would just like to say thank you for
having me. Um, I will continueto follow parody because I
have, I have thus far and Ithink it's fascinating. Um, so
I appreciate, I
Speaker 2 (20:46):
Appreciate the opportunity to talk with you.
Thank you for listening. If youenjoyed this episode, be sure
to subscribe to ALA's speakingof health law wherever you get
your podcasts. To learn moreabout a HLA and the educational
resources available to thehealth law community , visit
(21:07):
American health law.org .
Speaker 2 (00:04):
A HLA is pleased to present this special series
highlighting the top 10 healthlaw issues of 2025, where we
bring together thought leadersfrom across the health law
field to discuss the majortrends and developments of the
year. To stay updated on allthe major health law news,
subscribe to ALA's New HealthLaw Daily podcast. Available
exclusively for premiummembers@americanhealthlaw.org
(00:27):
slash daily podcast .
Speaker 3 (00:35):
Hello, everybody. My name is Christiana Finner , and
I'm an attorney at the law firmof Win and Weinstein in
Minneapolis, Minnesota. Ipractice in my firm's
healthcare regulatory group,and I am a , uh, member for
many years of the AmericanHealth Law Association
Behavioral Health PracticeGroup. I am currently the vice
(00:56):
chair for member engagement.
Um, I'm very pleased to be heretoday , um, on episode number
seven of our top 10 , um,issues in health Law 2025. Um,
joining me today is Noreen Ra ,who is a partner at Hush
Blackwell, and she is theco-author of an article , um,
(01:19):
entitled The Impact of the 2024Mental Health Parity and
Addiction Equity Act, finalRule in 2025, focused on
access. And , um, Noreen isgoing to answer some questions
for us today about , um, thearticle. And Noreen, I will
turn it over to you tointroduce yourself.
Speaker 4 (01:38):
Thank you so much, Christiana. It's, it's very
nice to be here. Thank you forinviting me to talk about a
topic that I care very muchabout and have worked in for
the, the better part of, of twodecades. Um, I'm a partner at
Hush Blackwell in thehealthcare regulatory practice
group and specialize in, inbehavioral health, but also in
(02:01):
healthcare reimbursement. Andthat's, that's where mental
health parity sits. Uh , priorto joining Hush , I worked
in-house at the NationalAssociation of Insurance
Commissioners where I got a, aheavy , a dose of Affordable
Care Act regulation. Uh, then Iwas general counsel for a
(02:22):
behavioral healthcare managedcare company for about eight
years, and now I'm, now I'm atHush , uh, working on, on the
same, same laws, different, Iguess different aspect,
different side,
Speaker 3 (02:37):
Different lens. Very good. Um, well, you obviously
have a lot of background inbehavioral health. Parody is a
huge thing. Um, and, you know ,um, the , these were very long
awaited revisions. What areyour thoughts generally on the
2024 final rule and , um, itsrequirements?
Speaker 4 (02:57):
So my overall thoughts are the 20 20 24 final
rule. Uh, basically there,there's, in my mind a , a vibe
shift. Uh, the departments ofLabor , uh, health and Human
Services and the TreasuryDepartment have indicated
through this rule that they areready to enforce. Um, and
(03:18):
they've been getting that kindawarming up towards that for,
for a long time. Um, just as,as background , uh, mia , which
I will probably frequently sayMIA or parody interchangeably,
but what I'm really referringto is the Federal Mental Health
Parity and Addiction EquityAct. And then we're talking
(03:41):
today about the 2024 finalrule, which builds on a 2013
final rule. So there's, there'sover a decade or close to a
decade, well, I guess over adecade, if you go back to 2008,
when, when this act was enactedof increasing enforcement,
(04:01):
increasing , um, I guessattention paid by the, the
federal regulators to howbehavioral health benefits and
are treated comparably tomedical surgical benefits , um,
MIAA is regulated by threedifferent agencies. So when I
(04:24):
say the departments, I'mreferring to a trifecta of the
departments of labor , um,which regulates fully insured
plans , um, or self-funded,sorry, not fully insured,
self-funded plans. My mistake ,uh, department of Health and
Human Services, which regulatesfully insured plans. And then
(04:45):
the Treasury Department, whichregulates church plans. So
those three together are thedepartments. And in this 2024
final rule, they've indicatedthe rate ready to enforce. Um,
they've built on the 2013 ruleyears of subregulatory guidance
and red flag documents issuedto the states. They've issued
(05:07):
reports to Congress, they'veexpressed the need to have
additional authority, whichthey received in the
Consolidated AppropriationsAct. So from a enforcement and,
and what the departments need ,um, they're ready to go. That
being said, the other takeawaythat I have from this role is
that the departments are stillstruggling with , with how to
(05:30):
comply with this lawthemselves. In , in my review,
in my estimation , um, they'restill changing definitions.
They are increasing , uh, andadding new concepts. Um, and
they are making dramaticchanges with, you know, in
regulation to how benefits willbe administered, not just for
(05:57):
mental health and, andsubstance use disorder
benefits, but all benefits,medical, surgical, and
behavioral health. So I reallythink this is a significant
rule. Um, it's, it's a lot gota lot in there. It's very
dense, but it is, in my view,the final step to , um, the
(06:18):
departments and particularlythe Federal Department of Labor
completing audits, finding, youknow, acts of non-compliance
and then sending letters tomembers and allowing ERISA
suits to proceed forward. Andthat's been the kind of
boogeyman lurking in thecorner. And it, it seems, it
(06:39):
seems pretty close right now.
Speaker 3 (06:42):
Good. Well, this is , um, you know, very gonna be
very interesting times with ,um, the final rule and, and
how, kind of how it intersectswith the new administration.
Tell us , um, tell us aboutsome of the changes in the 2024
final rule.
Speaker 4 (06:56):
Okay, so there are many , uh, one kind of major
underlying change is kind ofthe definition of mental health
benefits prior to this rule.
Um, and historically healthplans have had the discretion
to categorize their benefits inthe medical, surgical or
(07:16):
behavioral, and this is, theymake this decision through a
variety of factors. Um, asignificant one is what is the
nature of the condition beingtreated, but it's, it's not the
only factor as to why a benefitor procedure , um, gets , uh,
(07:38):
classified as one or the other.
In the 2024 final rule onechange is that the departments
specify , um, that the plansmust use the current , uh, DSM,
and that is a, a manual , um,that designates or lists out
(08:03):
mental health and, andbehavioral health conditions.
It, it isn't a benefitguidebook. It, it exists. I
think we're in , uh, well,we've had several additions of
it, but it is not intended, itnever has been intended to ,
uh, impact benefits. However,now the federal, the 2024 rule
(08:26):
says, look at the DSM, and ifthe treatment or procedure is
used to treat a mental healthcondition, then it is a mental
health benefit. That soundsvery, you know, small and just
a minor shift of wording. Andit is, but it's, it's a
significant change, especiallyfor those treatments and , and
(08:49):
procedures and services thatcan have both a medical
surgical and a behavioralhealth use. For example , um,
speech therapy, occupationaltherapy for , uh, under this
new rule will be treateddifferently depending on
whether this , the patient isreceiving speech therapy and
(09:11):
occupational therapy or autism,a behavioral health condition
in the DSM or , um, you know,an issue with the, a physical
issue with the, the mouth or ,um, you know, tongue a a purely
medical condition. Those accessto treatment now is, is, has to
(09:34):
follow the condition being ,um, treated, and that is a very
significant change. Anotherchange in this rule is the
requirement for plans, healthplans to proactively take
action, reasonable action, butstill action to address , um,
(09:55):
negative or instances ofinappropriate or lack of access
to parity to behavioral healthbenefits. Um, this is shown in
their dis in the department'sdiscussion of licensure types
and their network. Um, whereasprior to the 2024 rule plans
(10:15):
had to track and trend and ,and review what was happening,
but there was no affirmativerequirement to change their
network to add more licensuretypes, for example, for
behavioral health benefits orchange credentialing standards
to make it easier forbehavioral health licensure
(10:39):
licensed clinicians to get inversus medical surgical. That
is a wholly new , uh, balancingtest and , and way to look at
it .
Speaker 3 (10:49):
Noreen, switching kind of gears to , um, what we
kind of , uh, previewed , um,earlier was, you know, the
impact of administrationchanges , um, on mia . Do you
think that the Department ofGovernment Efficiency Doge or
the Supreme Court case , LoperBright , which recently came
(11:09):
down, will have an effect onMIA compliance and or
enforcement?
Speaker 4 (11:16):
Well, this is something I've been thinking a
lot about, and the short answerI think is yes , um, it will
have an effect. Um, so LoperBright came out last fall and
around the same time that theinterim final rule for the 2024
final rule was, was out andbeing reviewed. I'm not a LOPA
(11:37):
bright expert and or work inthis area. However , um, you
know , I do follow it andunderstand that, you know, the
Supreme Court overturned theChevron doctrine in that case,
which allowed deference toexecutive agencies, broadly
speaking. Um, the reason Ithink that Loper Bright may
(12:01):
have an impact or will have animpact if reviewed is because
meia from its outset , uh,going back to the 2013
regulation, and, and it's nodifferent in this 2024
regulation meia , as we know,it is largely a creature of
regulation as opposed tostatute. Um , meia itself is,
(12:24):
is pretty short , um, andentire concepts , um, for
example, the non-quantitativetreatment limitation or NQTL,
which is of much, much focus inthe 2024 Reg NQTL is, is a
concept that appeared in the2013 final regulation. It , it
(12:45):
doesn't go back to the, to thelaw. So , um, or actually even
the 2013 interim reg , finalreg. So given the structure of
Meia and what is happening at afederal level with , um, the
change in administration, I dothink if reviewed laws like MIA
(13:10):
are vulnerable because most ofthe teeth are, are built into
the reg as opposed to the lawitself. Um, and, and mia we've
had a, a decade of this , um,regulatory guidance and
sub-regulatory guidance, andthe departments are ready to
move on that regulatoryguidance. Um, a change or a
(13:35):
shift in how courts interpretthat regulatory guidance of
challenge, I think could ,could really have a, a very
significant impact on mia . Um,similarly with Doge, or maybe
not similarly, but you know, Ithink Doge may very well have
an impact. Um, MIA is regulatedor enforced by three agencies
(13:59):
working together, theDepartment of Labor, department
of Health and Human Servicesand Treasury. Um, we know that
treasury is undergoing quite a,a , a review, and we don't know
yet whether there will be achange to any of their scope
going forward. Treasury isresponsible for reviewing or
(14:21):
enforcing and regulating churchplans in Mepe , which is not
something intuitively that youwould think the Treasury
Department would have authorityover. Um, similarly, we don't
know what will happen withHealth and Human Services , um,
or the Department of Labor andits ability to enforce areas
(14:41):
of, of law that weretraditionally , um, reserved to
the states. The way that the ,um, the regulatory framework or
the enforcement structure inMIAA is set up is that in , in
, in the 24 Reg and, and reallywith the Consolidated
Appropriations Act, theDepartment of Labor has the
(15:04):
ability to kind of step out infront and conduct the audits
and, and do the work, and thenthey share their findings with
other agencies in the states.
However, this is, this is a , abit of a flip from how re
insurance has been regulatedfor, for 150 years, which it's
traditionally been a functionof state insurance regulation
(15:25):
that changed with theAffordable Care Act. And then
now we've, we've got federalenforcement in a very big way.
Um, we don't know the extent ofthat, whether that framework,
what that's going to look like, um, after dos. And I think
that's , uh, I think that'sdefinitely something to, to pay
(15:47):
close attention to.
Speaker 3 (15:50):
Along those lines, Mia isn't a well-known law ,
um, which, you know, is , um,somewhat regrettable. Um, how
would it impact an everydayconsumer of healthcare or
someone that doesn't workaround benefits and managed
care?
Speaker 4 (16:08):
Absolutely. Um, people aren't, most people
don't even know what Meia is.
They're not inclined to thinkabout behavioral health
benefits unless they need theservice. And when you need the
service, you then you need it.
Um, however, under theAffordable Care Act , uh, you
know, broadly speaking, when ahealth plan offers mental
(16:30):
health and substance usedisorder benefits or
collectively behavioral healthbenefits, when they offer those
and they sell those, they needto provide those at parity. Um,
and then that's where all thetesting comes in. And , and you
get the, the complicated , um,definitional framework. The
testing requirements for parityapply across all benefits. It's
(16:51):
not just behavioral, it's a ,um, you have to look at what
the health plan is doing on themedical side in order to
determine whether what the planis doing on the behavioral side
is compliant or not. So thisrequires it's kind of forced
integration. Um, so thatproduces that kind of forced
(17:13):
integration. Plus, you know,compliance is really getting
ready to start pending Loperand Doge , um, that can present
some odd decisions and, andappear odd to the consumer. As
an example of some things thatmight change that you wouldn't
think of , um, because of, ofMeia is prior authorization ,
(17:37):
um, several years ago , um,maybe not even that far, you
know, not far in the past priorauthorization on medical
benefits going into inpatientin the hospital was pretty
rare. Um, however, now it'sback and we're finding health
plans that are requiring priorauthorization across all
benefits, every inpatient stay.
(17:57):
You must get a prior authbefore you go in. So why are
those things back? Well , Idon't have a , a crystal ball
or have any insightinformation, but parity
requires, you know,comparability and it also
prohibits a health plan fromtreating or , um, imposing
(18:20):
stricter and more stringentrequirements on the behavioral
health side. Then they do themedical. So in the prior
authorization situation, priorauthorization was a pretty
common , um, N-Q-T-L-I guess tobe used on the behavioral
health side, getting anauthorization before you go
inpatient into a , uh,behavioral health facility, not
(18:43):
so much on the medical side,but parity one, at least
intuitive outcome that thatappears to be playing out. Um,
you can't have that, you can'thave prior authorization on
behavioral and not a medicalsurgical. So in one sense,
maybe the departments had hopedthat prior authorization would
(19:06):
reduce and, and would disappearacross the board because you
don't do it on medical. Whywould you do it on behavioral?
That makes a lot of sense, andmaybe that does happen for some
plans, but an alternate way ,um, to be compliant is to
require prior authorization foreverything because then you're
(19:26):
not, you know, reducing or morestringent on behavioral health.
Everybody has the same high barto get inpatient. So those are
some of the , um, the ways thatMIA compliance and the , the
decisions that plans are makingbehind the scenes , um, can
(19:48):
impact those who, who aren'tpaying attention to behavioral
health benefits at all.
Speaker 3 (19:55):
Good. Well, this has been , um, very informative.
I've really enjoyed getting thechance to speak with you about
the changes .
Speaker 4 (20:03):
Thank
Speaker 3 (20:03):
You . The final rule, and if you all in the
audience have also enjoyed thisvery much, encourage you to get
involved with the behavioralhealth practice group within
the A HLA. It is a fantasticresource for , um, articles
like this and a great way toget to know other people who
practice in the behavioralhealth space. Um, and Noreen,
(20:27):
any final , uh, thoughts or orwords from you on , uh, the
final rule and , um, AIA goingforward?
Speaker 4 (20:35):
No, I would just like to say thank you for
having me. Um, I will continueto follow parody because I
have, I have thus far and Ithink it's fascinating. Um, so
I appreciate, I
Speaker 2 (20:46):
Appreciate the opportunity to talk with you.
Thank you for listening. If youenjoyed this episode, be sure
to subscribe to ALA's speakingof health law wherever you get
your podcasts. To learn moreabout a HLA and the educational
resources available to thehealth law community , visit
(21:07):
American health law.org .
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