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Marriage and Family Therapy Coverage


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Hello Benefits Linkers! 

We have a self-funded client whose attorney mentioned the DOL recently subpoenaed a TPA regarding plan documents that exclude Marriage & Family Therapy. The attorney feels the self-funded medical plan may want to be amended to cover it based on the DOL's subpoena/the topic being on the radar. Does anyone have knowledge of which case this is in reference to? If so, can you please link it? 

The TPA (BUCA) hasn't heard anything of such a subpoena and have no clients that cover Marriage and Family Therapy. I've got e-mails out to our internal Compliance Team and the TPA's. Any other advice? We do not have a client with any carrier that covers this type of therapy at present. 

Thank you!

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Consider that there might not yet be a case.

The Employee Retirement Income Security Act of 1974 grants the Secretary of Labor broad investigation powers. These include powers to require almost anyone to submit records and other information. Labor’s subagencies, including the Employee Benefits Security Administration, sometimes do this using a summons or subpoena, especially if a service provider requests this (often, so the service provider is not perceived as voluntarily revealing its client’s information).

ERISA § 504, 29 U.S.C. § 1134 http://uscode.house.gov/view.xhtml?req=(title:29%20section:1134%20edition:prelim)%20OR%20(granuleid:USC-prelim-title29-section1134)&f=treesort&edition=prelim&num=0&jumpTo=true; see also EBSA Enforcement Manual, chapter 33.

About whether a health plan must or should cover marriage-and-family therapy, one presumes the plan’s sponsor will want its lawyers’ advice.

Peter Gulia PC

Fiduciary Guidance Counsel

Philadelphia, Pennsylvania

215-732-1552

Peter@FiduciaryGuidanceCounsel.com

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I don't know that there is a case, but can tell you that the DOL has issued a subpoena to a TPA in AR asking for plans with that exclusion (as well as a couple of others).  Unclear what the ultimate goal is - to force TPA to stop allowing the exclusions or to target certain plans.  I am not seeing how an exclusion for marital therapy or family therapy altogether could be an issue (you could need therapy due to problems created by a medical condition) - unless the DOL views these services as potentially encompassing mental health conditions.  

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What I'm struggling with is even if this is a MHPAEA "mental health benefit," what prevents the MFT exclusion?

I was looking through the MHPAEA compliance checklist, and I'm thinking maybe this note is relevant:

https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/self-compliance-tool.pdf

Under the MHPAEA regulations, if a plan or issuer provides mental health or substance use disorder benefits in any classification described in the MHPAEA final regulation, mental health or substance use disorder benefits must be provided in every classification in which medical/surgical benefits are provided. See 26 CFR 54.9812-1(c)(2)(ii)(A), 29 CFR 2590.712(c)(2)(ii)(A), 45 CFR 146.136(c)(2)(ii)(A). Under the MHPAEA regulations, the six classifications* of benefits 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

NOTE: If a plan or coverage generally excludes all benefits for a particular mental health condition or substance use disorder, but nevertheless includes prescription drugs for treatment of that condition or disorder on its formulary, the plan or coverage covers MH/SUD benefits in only one classification (prescription drugs). Therefore, the plan or coverage would generally be required to provide mental health or substance use disorder benefits with respect to that condition or disorder for each of the other five classifications for which the plan also provides medical/surgical benefits.

 

That Rx tie-in is the only way I'm seeing a potential parity issue with an exclusion for MFT generally.  It will be interesting to learn what the hook is here since this is probably going to be important for a lot of plans to understand.

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  • 3 weeks later...

I think it's important to be aware that Marriage and Family Therapy is just a type of therapy that can be used to treat diagnosed conditions such as anxiety, depression and other mental health disorders. For example, treatment for an adolescent with depression may involve family therapy sessions. I don't know why Marriage and Family Therapy should be treated any differently than Individual Therapy from a coverage standpoint.   

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