Medical Necessity and Contract Amendments Under Mental Health Parity (CMS-10556)

The final rule amends the Medicaid and CHIP regulations to implement the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. The final rule applies mental health parity requirements to Medicaid Managed Care Organizations (MCOs), Section 1937 Alternative Benefit Plans (ABPs), and the CHIP. The final rule also contains provisions related to the disclosure of information related to the reason for denial of reimbursement or payment for MH/SUD benefits. The text only clarifies the expectations for disclosing information concerning the denial of reimbursement or payment for MH/SUD benefits. It does not impose any new or revised third-party disclosure requirements.

The latest form for Medical Necessity and Contract Amendments Under Mental Health Parity (CMS-10556) expires 2022-11-30 and can be found here.

Availability of Information and the Criteria for Medical Necessity Determinations (Regulated Entities)

Federal Enterprise Architecture: Health - Health Care Services