Quantitative and Nonquantitative Treament Limitations: Where to Start

MHPAEA’s rule against discrimination applies to both quantitative treatment limitations and nonquantitative treatment limitations.

A quantitative treatment limitation is something like a cap on the number of visits or days of coverage.  These violations are fairly easy to spot and address.

Nonquantitative treatment limitations are by definition a broader concept — they include, for example, things like criteria and other utilization management tools. They violate MHPAEA if they are applied in a more restrictive manner for behavioral health than they are for physical health.  Discriminatory nonquantitative treatment limitations can be harder to nail down and address, but that does not mean that health insurers can do whatever they want – it just means that patients and providers need to pay careful attention, and maybe do a little more work.

Some medical necessity criteria are discriminatory on their face because they are more restrictive than widely accepted criteria (such as the medical necessity criteria promulgated by the American Society of Addiction Medicine).  A health plan is not allowed to just make up an arbitrarily constrained set of rules (unless, of course, they do the same thing for physical health, which is hopefully never the case).  To identify these violations, families and providers need to obtain criteria, but that is easy to do, because health plans health plans and insurers are required to provide these documents upon request. In fact health plans and insurers are required to provide not just criteria themselves, but also “the processes, strategies, evidentiary standards, and other factors used to apply a nonquantitative treatment limitation.”  29 C.F.R. § 2590.712(d) (3) (this citation is to Department of Labor MHPAEA regulations; identical language is found in the HHS and IRC regulations).  These additional documents can be extremely important — they might include, for example, a flowchart that directs how criteria are to be applied, and does so in a way that means nobody will ever get inpatient behavioral health treatment no matter what the criteria say.  Obtaining these documents is often an important first step in any attempt to identify (and eradicate) unlawful nonquantitative treatment limitations.

Advertisements