The Six Benefit Classifications
| Classification | Medical/Surgical Example | MH/SUD Must Be Equal or Less Restrictive |
|---|---|---|
| Inpatient in-network | $500/day copay for hospital admission | Psychiatric inpatient copay ≤ $500/day |
| Inpatient out-of-network | 40% coinsurance | Psychiatric inpatient OON coinsurance ≤ 40% |
| Outpatient in-network | $40 specialist copay | Therapy visit copay ≤ $40 |
| Outpatient out-of-network | 30% coinsurance | Therapy OON coinsurance ≤ 30% |
| Emergency care | $250 ER copay | Psychiatric ER copay ≤ $250 |
| Prescription drugs | Tier 2: $40 copay | Psychiatric drugs on same tier ≤ $40 |
Common QTL Violations
- Higher copays for mental health outpatient visits than for medical specialist visits
- Annual visit limits for mental health that do not apply to medical/surgical
- Higher deductibles for mental health inpatient than for medical inpatient
- Separate out-of-pocket maximums for mental health
- Day limits for psychiatric inpatient that do not apply to medical inpatient
QTL Audit
Pro Tip
Conduct a QTL audit by comparing the cost-sharing and limits for MH/SUD benefits to the corresponding medical/surgical benefits in each of the six classifications. This audit can be done with a simple spreadsheet. Any MH/SUD benefit that is more restrictive than the corresponding medical/surgical benefit is a potential MHPAEA violation.