Mental health parity: FAQs for members

Parity applies to the ways health plans manage treatment.

That includes practices such as:

• Approving care before it’s provided, or
• Reviewing a provider’s qualifications before they join our network 

These are called non-quantitative treatment limitations (NQTLs). That’s because they may affect the scope or duration of benefits for treatment. And they aren’t stated as a number, unlike a visit or dollar maximum.

This explains how our clinical management and network development policies, procedures, and practices comply with the NQTL requirements of the Mental Health Parity and Addiction Equity Act (MHPAEA). We base our analysis on the Aetna standard fully insured plan design.

We evaluate NQTL compliance on both comparability and stringency. We review the processes, strategies, evidentiary standards and other factors in applying a NQTL to MH/SUD and med/surg benefits for comparability in the factors and how stringently we apply those factors.

Employers that sponsor plans are responsible for determining plan compliance with MHPAEA. If you’re covered by a self-funded plan, contact your plan sponsor for your plan’s NQTL comparability analysis.

MHPAEA requires plans to compare benefits within a classification. There are six classifications to carry out MHPAEA requirements. The law doesn’t define which benefits fall under each category.

The classifications include:

1. Inpatient in-network
2. Inpatient out-of-network
3. Outpatient in-network
4. Outpatient out-of-network
5. Emergency
6. Prescription drugs

Health plans can also subclassify outpatient visits into office visits and “all other.” The “all other” is for outpatient services provided by a care professional where the main trait of the service is something other than direct, personal contact with the professional. These services usually rely on a high-tech test or device, or surgery. Multi-tier network plans may also subclassify in-network benefits by network tier.

Precertification is an important process. It’s approval you get for care before receiving the care. This helps you know if the care is covered by your health plan. Be sure to check with your plan to learn what kind of service needs this approval.

Precertification is also called:*

• Authorization
• Certification
• Prior authorization

In network

Your network physician or PCP will get precertification, if needed, before you get care. Network providers can’t bill you if they don’t ask us for precertification.

If your physician or PCP requests precertification and we deny it — and you still choose to get the care — you’ll have to pay for it yourself.

Out of network

When you go to an out-of-network provider, you need to get precertification, if needed, from us.

If you don’t get precertification:

• Your benefits may be reduced, or the plan may not pay. For details, check your schedule of benefits.
• You’ll be responsible for the unpaid bills.
• Your out-of-pocket expenses won’t count toward your deductible or maximum out-of-pocket limit, if you have any.

Want to learn more?

• You can find a list of in-network services that require precertification. 
• You can find a list of out-of-network services in your certificate of coverage or summary plan description.

Still have questions? Call Member Services at the toll-free number on your ID card.

We base our precertification process on our accreditation standards* and state and federal law.

Here’s how it works: 

First, clinical support staff review the information your provider sends us. Support staff aren’t licensed health care providers. They can only make coverage determinations that don’t require clinical review. For example, support staff can deny a request for a member who isn’t covered under the plan, or for a service that’s never covered. 

Next, if a precertification request needs clinical review, it’s sent to a licensed clinician. This includes registered nurses (RNs), licensed clinical social workers (LSCWs) and physicians. If a licensed clinician can’t approve coverage, they send the request to a medical director or a consulting physician, psychiatrist, psychologist or board-certified behavior analyst-doctoral (BCBA-D). 

The licensed clinician reviews the medical records your provider sent us. If they determine the service is medically necessary, they can approve it. If not, they send the request to a medical director or the designated psychologist/BCBA-D for the coverage determination. The licensed clinician or medical director uses their training and expertise to apply the right clinical review criteria to the request. (Check our medical necessity FAQs for more info about clinical review criteria.) 

We’ll communicate the determination to you and your provider. If we deny your request, you may appeal. Or your treating provider may have a peer-to-peer consultation with our physician.

Our national precertification list committee decides which services to add to, keep on or remove from the precertification list. The committee is made up of clinicians and other subject matter experts. They have expertise in mental health, substance use disorder and medical/surgical treatment.

The committee also reviews the precertification list every year to make sure the services still require precertification. They must document the reasons for the decision.

This proves that we’re applying the factors comparably, and not more stringently, to MH/SUD services.

The same factors and sources, and the same national precertification list policy and procedure, apply to MH/SUD and med/surg benefits in deciding which services to add to, keep on or remove from the national precertification list.

The same factors and sources, and the same national clinical services policies and procedures, apply to handling precertification requests for MH/SUD and med/surg benefits.

As written, we apply this NQTL comparably, and not more stringently, to MH/SUD benefits.

Yes. We monitor comparability and stringency by reviewing what services have been added and removed from the participating provider precertification list. Fewer MH/SUD services need precertification than med/surg services. Each service we added to or kept on the participating provider precertification list met the criteria for precertification. 

We also review denial rates and turnaround times for precertification reviews. For our book of business, we deny a lower percentage of MH/SUD authorization requests. The average decision time is quicker for MH/SUD reviews than for med/surg reviews. 

We also check if the process for applying utilization management criteria to MH/SUD services is comparable and no more stringent than the process for applying utilization management criteria to med/surg services. We do this by evaluating medical directors and utilization management clinicians for consistency and accuracy through our internal quality review and inter-rater reliability process.

Our goal is to help make sure you get the right level of care, at the right time. And at a reasonable cost. We may evaluate your care while you’re in the hospital or in outpatient treatment. This is called concurrent review. This process helps determine if your plan covers the treatment under review.

During concurrent review, we:

• Collect information from the care team about your condition and progress.
• Use this information to determine coverage.
• Inform everyone involved in your care about the coverage determination.
• Work on a discharge plan and continuing care plan early in the stay.
• Review this plan during the stay.
• Identify quality of care concerns and patient safety events for further review.
• Refer you to our covered specialty care programs, if needed. These programs may include case management, disease management, behavioral health, the National Medical Excellence Program® and women's health programs, such as the maternity program and infertility program.

We may perform concurrent review by phone, fax or on site at the facility.

These services are subject to concurrent review:

• Inpatient admissions that go beyond the first precertification authorization
• Partial hospitalization program treatment that goes beyond the first precertification authorization

Your network physician or PCP will get concurrent review, if needed. Network providers can’t bill you if they don’t ask us for a concurrent care claim extension. But if your physician or PCP requests an extension and we deny it — and you still choose to get the care — you’ll have to pay for it yourself.

When you use an out-of-network provider, you need to get a required concurrent care claim extension from us. Your certificate of coverage lists which services require a concurrent claim extension and what happens if you don’t request one.

You or your provider should start concurrent review:

• Before the authorized coverage period under the first precertification, or
• Before the previous concurrent review expires

Your provider will send us updated information about your condition, progress and treatment/discharge plan.

Here’s how it works:

First, utilization management clinicians, who are registered nurses or licensed behavioral health clinicians, start the review. The licensed clinician reviews the medical records your provider sent us. If they determine the service is medically necessary, they can approve it. If not, they forward the request to a medical director or the designated psychologist/BCBA-D for the coverage determination. The licensed clinician or medical director uses their training and expertise to apply the right clinical review criteria to the request. (Check our medical necessity FAQs for more info about clinical review criteria.)

We’ll communicate the preapproval determination to you and your provider. If we deny your request, you may appeal. Or your treating provider may have a peer-to-peer consultation with our physician.

Yes. The same factors and sources apply to MH/SUD and med/surg benefits in deciding which services are subject to concurrent review. The same factors and sources, and the same national clinical services policies and procedures, apply to handling concurrent review requests for MH/SUD and med/surg benefits.

As written, we apply this NQTL comparably, and not more stringently, to MH/SUD benefits.

Yes. Aetna monitors denial rates and turnaround times for concurrent reviews. For our book of business, we deny a lower percentage of MD/SUD authorization requests. The average decision time is quicker for MD/SUD reviews than for med/surg reviews.

We also check if the process for applying utilization management criteria to MH/SUD services is comparable and no more stringent than the process for applying utilization management criteria to med/surg services. We do this by evaluating medical directors and utilization management clinicians for consistency and accuracy through our internal quality review and inter-rater reliability process.

Retrospective review is the process of determining coverage after you’ve received treatment.

During this review, we:

• Confirm member eligibility and benefit coverage
• Analyze your patient care data to support coverage determination
• Receive supporting clinical documentation from providers with the payment request

Retrospective review happens when precertification was required but didn’t take place.

Licensed clinicians perform retrospective review after services have already been provided. This includes registered nurses (RNs), licensed clinical social workers (LSCWs) and physicians. If a licensed clinician can’t approve coverage, they send it to a medical director or a consulting physician, psychiatrist, psychologist or board-certified behavior analyst-doctoral (BCBA-D).

The licensed clinician reviews the medical records your provider sent us. If they determine the service is medically necessary, they can approve it. If not, they forward the request to a medical director or the designated psychologist/BCBA-D for the coverage determination. The licensed clinician or medical director uses their training and expertise to apply the right clinical review criteria to the request. (Check our medical necessity FAQs for more info about clinical review criteria.)

We perform retrospective review for:

• Out-of-network inpatient services that weren’t precertified, and
• Out-of-network outpatient services that are on the member precertification list and weren’t precertified

For In-network services, we perform retrospective review in these circumstances:

• When an in-network psychiatric hospital or other MH/SUD or med/surg facility that isn’t a hospital or children’s hospital didn’t precertify or give timely notice of inpatient admission
• When required by state law or our contract with a facility
• When provider precertification requirements are waived due to a state or federal disaster declaration
• When there’s a valid reason to not precertify or give timely notice (e.g., member was unable to provide insurance information at the time)

For emergency services, we perform retrospective review on MH/SUD and med/surg services where the diagnosis code signals a condition that potentially was not an “emergency” under the federal “prudent layperson” standard.

The same factors and sources, and the same national clinical services policies and procedures, apply to handling retrospective review requests for MH/SUD and med/surg benefits.

As written, we apply this NQTL comparably, and not more stringently, to MH/SUD benefits.

Yes. Aetna monitors comparability and stringency by reviewing denial rates and turnaround times for MH/SUD and med/surg retrospective reviews.

We also check if the process for applying utilization management criteria to MH/SUD services is comparable and no more stringent than the process for applying utilization management criteria to med/surg services. We do this by evaluating medical directors and utilization management clinicians for consistency and accuracy through our internal quality review and inter-rater reliability process.

As defined in the standard certificate of coverage, medically necessary or medical necessity means: Health care services or supplies that prevent, evaluate, diagnose or treat an illness, injury, disease or its symptoms, and that are all the following, as determined by us within our discretion:

• In accordance with “generally accepted standards of medical practice”
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your illness, injury or disease
• Not primarily for your convenience, the convenience of your physician, or other health care provider
• Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your illness, injury or disease

Generally accepted standards of medical practice mean:

• Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and
• Following the standards set forth in our clinical policies and applying clinical judgment

All inpatient, outpatient and emergency care services are subject to medical necessity review.

The Aetna clinical policy council is made up of pharmacists and medical directors from various departments. This council provides guidance and advice to our chief medical officer (CMO) and vice president for clinical policy on specific clinical topics under review. Together, they determine whether medical services, drugs and devices are considered experimental, cosmetic or medically necessary.

The council applies the factors, sources and evidentiary standards to develop (in the case of Aetna clinical policy bulletins) or approve (in the case of clinical guidelines published by third parties) evidence-based guidelines that are used by Aetna clinicians to evaluate the medical necessity of a service, drug or device. The council has approved the clinical policy bulletins to be used by Aetna clinicians in making medical necessity determinations.

Yes. We use the same strategy, certificate of coverage definition of “medical necessity”, and factors/sources/process to determine medical necessity for both MH/SUD and med/surg services. 

The Aetna clinical policy bulletins and third-party clinical guidelines clinicians use to make mental health and substance use disorder and medical/surgical medical necessity determinations are developed and adopted by the same clinical policy council. 

As written, we apply this NQTL comparably to MH/SUD and med/surg benefits. And we apply this NQTL no more stringently to MH/SUD benefits than we do for med/surg benefits.

Yes. We review decision denial rates for precertification, concurrent review and retrospective review to compare how we determine medical necessity for MH/SUD and med/surg services.

For our book of business, we deny a lower percentage of MH/SUD care based on medical necessity compared to med/surg denials based on medical necessity.

In operation, we apply the medical necessity determinations comparably, and not more stringently, for MH/SUD services compared to med/surg services.

Sequenced treatment means one treatment after the other.

This means we:

• First, apply evidence-based guidelines that recommend the use of less invasive, most cost-effective treatments.
• Then, recommend moving to more invasive, or more costly treatments, if the less invasive treatments aren’t working.

A treatment plan is a plan of care based on each individual.

It includes:

• Defined target behaviors
• Recorded frequency, rate, symptom intensity/duration or objective measures of baseline levels
• Quantifiable criteria for progress

Certain MH/SUD and med/surg services are subject to sequenced treatment protocols. Or they may require a treatment plan as part of the medical necessity review.

The Aetna clinical policy council is made up of pharmacists and medical directors from various departments. This council provides guidance and advice to our chief medical officer (CMO) and vice president for clinical policy on specific clinical topics under review. Together, they determine whether medical services, drugs and devices are considered experimental, cosmetic, or medically necessary. This includes whether a sequenced treatment requirement applies, or a treatment plan is required.

The council applies the factors, sources and evidentiary standards to develop Aetna clinical policy bulletins. These are evidence-based guidelines and clinical criteria used by Aetna clinicians and clinical reviewers to apply a sequenced treatment requirement or treatment plan to a requested service, drug or device. The council has approved the clinical policy bulletins to be used by Aetna clinicians and clinical reviewers in making medical necessity determinations. This includes whether to require a sequenced treatment protocol or a treatment plan.

Yes. We apply the same strategy, certificate of coverage definition of “medical necessity”, and factors/sources/process to determine medical necessity for both MH/SUD and med/surg services. This includes whether to require a sequenced treatment protocol or a treatment plan. Clinicians and clinical reviewers use Aetna clinical policy bulletins to apply sequenced treatment protocols and treatment plans to MH/SUD and med/surg procedures.

As written, we apply this NQTL comparably, and not more stringently, to MH/SUD benefits.

Yes. Aetna applies sequenced treatment protocols and treatment plans comparably, and not more stringently, for MH/SUD services compared to med/surg services.

A negotiated charge is:

• An amount a network provider has agreed to accept, or
• An amount we’ve agreed to pay them or a third-party vendor (including any administrative fee in the amount paid)

We’ve contracted with providers to provide covered services to you. These providers make up the network for your plan. You may choose a network provider from the online directory through your member website.

You won’t have to submit claims for services you receive from network providers. Your network provider will take care of that for you. And we’ll pay the network provider directly for what the plan owes.

We set reimbursement rates based on:

• The provider’s license and specialty
• The type of service or procedure
• The Medicare rate for the service or procedure
• Market dynamics

Network providers agree to accept the negotiated charge as payment in full. Your plan may have a deductible, copay or coinsurance.

Yes. The same factors and sources, and the same rate development policy and procedure, apply to MH/SUD and med/surg benefits. 

As written, we apply this NQTL comparably, and not more stringently, to MH/SUD benefits.

Yes. We monitor comparability and stringency by auditing standard reimbursement rates. 

In operation, we use the same processes and strategies to negotiate reimbursement rates with MH/SUD network providers as we use with med/surg network providers.

The recognized charge is the amount of an out-of-network provider’s charge that’s eligible for coverage. You pay all charges above this amount. The recognized charge depends on the geographic area where you get the service or supplies.

An out-of-network provider doesn’t have a contract with our health plan. This provider is also known as “nonparticipating or “nonpreferred.” You might pay more when you visit this kind of doctor, hospital or other health care professional.

The recognized charge doesn’t apply to involuntary services. These are services or supplies that are:

• Provided at a network facility by an out-of-network provider
• Not available from a network provider
• An emergency service

We follow state and federal law to determine the recognized charge for emergency and other involuntary out-of-network services.

Your certificate of coverage or summary plan description shows how we calculate the recognized charge for specific services or supplies. The method we use depends on your plan. But it will be the same for MH/SUD and med/surg benefits.

Your plan may have a deductible, copayment or coinsurance. Out-of-network providers may not accept the negotiated charge as payment in full.

To learn how we pay for out-of-network care, check your health plan documents. You can also call Member Services at the number on your Aetna ID card.

Yes. The same factors and sources, and the same out-of-network reimbursement methodology, apply to MH/SUD benefits and med/surg benefits.

As written, we apply this NQTL comparably, and not more stringently, to MH/SUD benefits.

Yes. We monitor comparability and stringency by reviewing reimbursement rates.

In operation, we use the same method to calculate the recognized charge for all out-of-network providers.

Network adequacy is a health plan’s ability to:

• Have enough providers in its network, and
• Make sure those providers can treat members in a timely manner

This includes primary care, specialists, mental health and substance use disorder providers, as well as other health care service providers.

We strive to make sure the number and variety of mental health and substance use disorder and med/surg providers in our network meets the needs and preferences of our members.

We check our provider network against standards set by state law (where applicable) or to meet our accreditation requirements. This means checking whether our providers are located close enough to our members. We also check the appointment wait times for our network providers.

Yes. The processes, strategies and evidentiary standards for maintaining and monitoring network adequacy are comparable for MH/SUD and med/surg providers. 

As written, Aetna maintains network adequacy policies and practices that equally apply to MH/SUD and med/surg.

Yes. Aetna monitors network availability and network accessibility reports for MH/SUD and med/surg providers.

We look at:

• The ratio of in-network providers to members
• The distance members need to travel to an in-network office location
• Wait times for routine and follow-up appointments
• After-hours availability

In operation, we use the same processes and strategies to ensure there are sufficient numbers and types of MH/SUD and med/surg providers in our network.

Before a health care professional joins the Aetna network, we collect and verify info about their professional qualifications. This is called credentialing.

This includes:

• Relevant training
• Licensure
• Certification and/or registration to practice in a health field
• Academic background, and more

We also review whether each provider meets professional competence and conduct standards.

Our participation standards and credentialing processes meet the National Committee for Quality Assurance (NCQA) accreditation requirements for health plans and managed behavioral health organizations. We’ve outlined these criteria for providers and facilities in the Aetna network participation criteria document.

First, providers who wish to join the Aetna network complete a credentialing application. This includes professional education and training, license, board certification, and other needed information.

To participate in our network, each provider needs to meet core criteria, including:

• Professional qualifications
• Availability of services
• Office/facility environment
• Professional liability insurance
• Professional competence and conduct
• Other criteria specific to the type of provider

Next, our credentialing staff checks the information based on state, federal and accrediting body requirements, including primary source verification.

We recredential providers every three years. We also monitor providers for member complaints and concerns about professional conduct and competence.

Yes. We list the network participation standards for MH/SUD and med/surg facilities and providers in the network participation criteria document. In most cases, these standards are identical. And where not identical, they are as comparable. 

We create and monitor our credentialing processes for MH/SUD and med/surg facilities and providers to align with written policies that equally apply to both MH/SUD and med/surg facilities and professionals.

Yes. To compare the credentialing of MH/SUD and med/surg providers and facilities, we review the number of applications we approved and denied for these providers and facilities. 

In operation, the credentialing denial rate and turnaround time is no more stringent for MH/SUD providers and facilities.