Mental Health Parity Act

Essential benefits information at your fingertips

The Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. MHPAEA supplements prior provisions under the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits.

Key components of MHPAEA include the following

  • If a group health plan includes medical/surgical benefits and mental health benefits, the financial requirements (e.g., deductibles and co-payments) and treatment limitations (e.g., number of visits or days of coverage) that apply to mental health benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits;
  • If a group health plan includes medical/surgical benefits and substance use disorder benefits, the financial requirements and treatment limitations that apply to substance use disorder benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits;
  • Mental health benefits and substance use disorder benefits may not be subject to any separate cost sharing requirements or treatment limitations that only apply to such benefits;
  • If a group health plan includes medical/surgical benefits and mental health benefits, and the plan provides for out of network medical/surgical benefits, it must provide for out of network mental health benefits;
  • If a group health plan includes medical/surgical benefits and substance use disorder benefits, and the plan provides for out of network medical/surgical benefits, it must provide for out of network substance use disorder benefits;
  • Standards for medical necessity determinations and reasons for any denial of benefits relating to mental health benefits and substance use disorder benefits must be made available upon request to plan participants;
  • The parity requirements for the existing law (regarding annual and lifetime dollar limits) will continue and will be extended to substance use disorder benefits.

For complete information regarding your rights under the Mental Health Parity and Addiction Equity Act, please visit the Department of Labor website at: www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-and-substance-use-disorder-parity

Military leave

Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty status in the National Guard or Reserves in support of a contingency operation may use their 12-week leave entitlement to address certain qualifying exigencies.

Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briefings. FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered service member during a single 12-month period.

A covered service member is a current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on active duty.

Eligible employee

To be eligible for FMLA benefits, an employee must satisfy ALL of the following conditions:

  • Have worked for the employer for a total of 12 months;
  • Have worked at least 1,250 hours over the previous 12 months; and
  • Work at a location in the United States or in any territory or possession of the United States where at least 50 employees are employed by the employer within 75 miles.

While the 12 months of employment need not be consecutive, employment periods prior to a break in service of seven years or more need not be counted unless the break is occasioned by the employee’s fulfillment of his or her National Guard or Reserve military obligation.

Medical certification

The Certification of Health Care provider forms are available on the Department of Labor website as well as through your employer.

A separate Certification of Health Care provider form is required for each condition an employee is requesting leave for.

An employer may use a health care provider, a human resource professional, a leave administrator, or a management official to authenticate, review, and/or clarify a medical certification of a serious health condition.

An employer can require a second or third medical opinion (at the employer’s expense).

Health insurance administration
  • If an employee fails to pay his/her share of the health insurance premium during leave, the regulations permit the employer to cancel their insurance.
  • There is a required minimum grace period of thirty days and the employer must send a written notice of the cancellation at least fifteen days before the coverage will cease.
  • Once the employee returns to work, health insurance must be restored without condition.
Twelve month period determined for FMLA
An employer may choose the method for determining the twelve month period. Most employers calculate it on a rolling year basis starting at the time the FMLA leave begins.
Notification requirements

Employees must provide 30-day advance notice of the need to take FMLA leave when the need is foreseeable. When 30-day notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer’s normal call-in procedures.

Employers require that an employee’s request for leave due to a serious health condition affecting the employee or a covered family member be supported by an authorized health care provider.

Maintenance of health benefits

FMLA does not require continuation of non-health benefits but all the employee’s benefits must be restored to their previous status upon return to work. If a lapse occurs, the employer cannot require current evidence of insurability or exclude coverage for conditions arising while the employee was on FMLA leave and not covered by the plan.

Premium payment

If an employer elects to continue health coverage for an employee by paying the employee’s share and the employee fails to return to work at the end of FMLA leave, the employer may recover all of the health benefit premiums it paid for group health coverage (both the employer’s share and the employee’s share) during the period of unpaid FMLA leave.

This information is intended to be general and informational in nature, and is not intended to provide you with legal, medical, tax, financial planning or other professional advice.