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MHPAEA summary: precertification, NQTLs, and parity processes
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Summarizes Aetna's Mental Health Parity and Addiction Equity Act (MHPAEA) analysis and describes prior authorization (precertification) processes, factors, sources, and timelines affecting mental health/substance use disorder and medical/surgical benefits; intended for members, providers, and regulators (Maryland report summary).
No material clinical or coverage changes in this revision.
Coverage Criteria and NQTL Findings
Prior authorization development and decision criteria
Factors, sources, and evidentiary standards used to develop prior authorization lists, administration processes, and approval/denial criteria.
ALL of the following
- Primary evidentiary sources include well-conducted clinical trials or cohort studies published in peer-reviewed literature; Aetna Clinical Policy Bulletins (CPBs); MCG care guidelines; NCCN treatment guidelines; and specialty-specific criteria such as ASAM, LOCUS/CALOCUS/CASII.
- Drug-specific sources include FDA labeling, peer-reviewed literature, therapeutic class reviews, drug monographs, utilization trend reports, and consideration of drug pipeline and safety data.
ALL of the following
- Clinical appropriateness in terms of type, frequency, extent, site, place of service, and duration.
- Patient-specific factors: age, comorbidities, complications, treatment response/progress, need for skilled care, psychosocial situation, and treatment setting (including home environment).
- Cost-effectiveness considerations where multiple clinically equivalent treatments exist (preferred placement of less costly equally efficacious options).
- State and federal law and NCQA utilization management standards guide timelines and processes.
ALL of the following
- Selection of services subject to prior authorization is governed by written lists (National Precertification List/Aetna Participating Provider Precertification List) and applies consistently across M/S and MH/SUD classifications.
- Clinical review and medical necessity determinations are made by clinicians using the same Clinical Policy Council, CPBs, and third-party guidelines; application and governance do not differ by MH/SUD vs M/S.
- Committees (FRC and P&T) and PBM pharmacists review formulary and utilization management decisions using the same monographs, therapeutic class reviews, meeting processes, and voting procedures regardless of drug category.
ALL of the following
- Timeliness standards follow NCQA and applicable state rules (e.g., Maryland requirement that non-urgent precertification requests be completed within 2 working days after receipt of needed information).
- Operational timeframes for notification include non-emergency precertification lead time (call at least 14 days before scheduled admission), emergency admission notification within 48 hours, and approval validity periods (approvals valid for 180 days).
- Expedited/medical exception processes are available for precertification, step therapy, quantity limits, and non-covered drugs with expedited decisions within 24 hours when applicable.
ALL of the following
- Internal Quality Reviews (IQR) and Inter-Rater Reliability (IRR) audits are performed (2023 audits cited) to assess consistent application of criteria and comparability of MH/SUD and M/S determinations.
- Operational data review includes analysis of approval/denial rates and non-formulary request volumes to confirm NQTLs are not applied more stringently to MH/SUD benefits.
Medical necessity and prior authorization criteria (MH/SUD and M/S)
Medical necessity determinations for both MH/SUD and M/S are made using the same Certificate of Coverage definition, factors, sources, and processes.
ALL of the following
- Clinicians apply the same written medical necessity definition from the Certificate of Coverage for both MH/SUD and M/S.
- Guidelines and tools used include Aetna Clinical Policy Bulletins (CPBs), MCG, NCCN, ASAM Criteria, LOCUS/CALOCUS/CASII, and ABA guidance as applicable to the condition or population.
ALL of the following
- Reviews consider clinical appropriateness (type, frequency, extent, site, duration), patient age, comorbidities, complications, treatment progress, need for skilled care, psychosocial circumstances, and safety concerns.
ALL of the following
- Aetna applies the same processes, factors, and evidentiary standards to determine medical necessity for MH/SUD and M/S; IQR and IRR audits in 2023 show comparable or slightly higher accuracy for MH/SUD determinations and fewer denials for MH/SUD in operation.
ALL of the following
Applies to
- In-network inpatient services
- In-network outpatient (all other) services
- Prescription benefit classifications where drugs require prior authorization
- Out-of-network outpatient MH/SUD precertification is not required for Maryland-sitused policies as of 01/01/2023; in-network participating providers are responsible for obtaining precertification for listed services.
ALL of the following
- If precertification is denied, Aetna explains reasons and provides instructions for review (appeals/complaints).
- Medical exception and expedited request procedures are available to providers/members, including submission via Availity, phone, fax, or mail; expedited decisions made within 24 hours when criteria met.
Prescription drug NQTL and formulary criteria conclusions
Findings and conclusions regarding application of prescription drug NQTLs and formulary design to MH/SUD versus MED/SURG drugs.
ALL of the following
- Prior authorization and formulary NQTLs are not applied more stringently to MH/SUD drugs than to MED/SURG drugs, both as written and in operation.
- Formulary design and tier placement use the same factors, evidentiary standards, committee processes, and voting procedures for MH/SUD and MED/SURG drugs.
ALL of the following
- Testing showed prior authorization applied to a lower percentage of MH drugs and to zero percent of SUD drugs compared to MED/SURG; analyses at the drug-class level confirmed factors and sources are applied consistently.
- PBM pharmacists reviewed non-formulary request volumes and approval rates: of 363 non-formulary requests, 130 were MH/SUD; approval rate for MH/SUD requests was 34% versus 27% for MED/SURG (Advanced Control sample), demonstrating no more stringent treatment of MH/SUD.
ALL of the following
- FRC and P&T committees review MH/SUD and MED/SURG drugs together using the same monographs, therapeutic class reviews, and meeting processes; membership expertise does not differ based on drug category.
- Formulary decisions consider clinical evidence, FDA labeling, cost-effectiveness, therapeutic alternatives, and utilization data in the same manner for all drugs.
ALL of the following
- Members may request medical exceptions to prior authorization, step therapy, or quantity limits; if approved, medically necessary outpatient prescription drugs are covered per plan design and member cost-sharing applies after deductible.
- Expedited decisions for medical exceptions are available (24-hour expedited timeframe).
Formulary Design NQTL Parity Conclusion
Formulary design and tier placement NQTL — written policies and operational application.
ALL of the following
- No separate policies or procedures exist for MH/SUD drug formulary design versus MED/SURG; the same processes, monographs, therapeutic class reviews, and evidentiary standards are used for tier assignment decisions.
- Personnel and committee credentials are consistent across drug categories; meetings consider drugs together without regard to whether they treat MH/SUD or MED/SURG conditions.
ALL of the following
- In-operation analyses and testing of tiers show factors and sources are applied consistently across MH/SUD and MED/SURG drugs; non-preferred tier placements (tiers 3 and 5) are not more stringent for MH/SUD drugs and therapeutic alternatives exist in preferred tiers.
- PBM and formulary reviews support that tier placement decisions reflect drug-specific clinical evidence, cost-effectiveness, and availability of alternatives rather than the therapeutic area alone.
ALL of the following
- Formulary and tier decisions are made through established committees (P&T, FRC) relying on drug monographs, therapeutic class reviews, and consistent voting processes; review cadence and committee governance apply equally to MH/SUD and MED/SURG drugs.
Provider Reimbursement NQTL Parity Conclusion
Provider reimbursement NQTL — participating and non-participating providers.
ALL of the following
- Participating provider reimbursement is implemented via the negotiated charge — the amount a network provider has agreed to accept or that Aetna has agreed to pay; the factors, strategy, processes, and evidentiary standards used to establish these rates are the same for MH/SUD and M/S providers.
ALL of the following
- Non-participating provider reimbursement is implemented via the allowable amount, which is the portion of an out-of-network provider's charge eligible for coverage and is determined the same way for MH/SUD and M/S claims (e.g., specified percentile of prevailing charges or percentage of Medicare rates as applicable).
- For HSCRC-regulated hospitals, rates set by HSCRC are used; for other claims, methodologies comply with Maryland law and applicable federal rules (e.g., median contracted rate calculations for surprise billing).
ALL of the following
- Aetna applies the same factors, strategy, processes and evidentiary standards to determine reimbursement for MH/SUD and M/S facility-based providers; methods for determining allowable amount and negotiated charge do not differ by benefit category.
Surprise Billing / Allowable Amounts
Payment methodology and surprise billing rules.
ALL of the following
- Negotiated charge: the amount a network provider has agreed to accept or that Aetna has agreed to pay; for surprise-billing calculations, the median contracted rate is used.
- Allowable amount: the portion of an out-of-network provider's charge eligible for coverage; members are responsible for charges above this amount and calculations depend on geographic area and plan-specific methods.
ALL of the following
- An out-of-network provider cannot balance bill for emergency services, certain non-emergency services at in-network facilities (unless appropriate notice and consent obtained), and out-of-network air ambulance services; surprise-bill payments are determined using the median contracted rate for similar providers in the market and subject to federal regulation adjustments.
- Any cost share paid will apply toward in-network deductible and out-of-pocket maximum; members may request external review regarding surprise-billing applicability.
ALL of the following
- For claims other than HMO, Aetna complies with Maryland statutes (e.g., HB 959) regarding reimbursement and non-imposition of greater cost-sharing for emergency services; for surprise bills, qualifying payment amount methodology follows federal rules (45 C.F.R. §149.140(c)).
- Factors used in developing payment limitations include Maryland law, HSCRC rates, and federal law; HSCRC rates are applied for regulated hospitals and loaded into claim systems.
ALL of the following
- Methods and definitions for negotiated charge and allowable amount are applied the same to MH/SUD and M/S providers; evidence supports comparable application in operation.
Provider Shortage Strategies
Strategies to address provider shortages and network adequacy.
ALL of the following
- Aetna maintains sufficient numbers and types of M/S and MH/SUD providers and monitors network adequacy through required annual Maryland filings and internal analyses; geographic availability and numeric provider standards are defined in policy consistent with COMAR.
- Appointment access timeframes required by Maryland regulation apply to both M/S and MH/SUD (urgent care ≤72 hours; routine primary care ≤15 days; preventive/nonurgent specialty ≤30 days; nonurgent behavioral health/SUD ≤10 days).
ALL of the following
- In operation, Aetna monitors wait times and provider-to-member ratios and takes interventions to increase provider availability and accessibility when needed; actions for MH/SUD providers improved access from 2022 to 2023.
- Open panels and provider recruitment activities are used comparably across M/S and MH/SUD to address shortages.
ALL of the following
- Network availability: geographic distribution of appropriate practitioner types and counts; network accessibility: members' ability to receive timely care (schedule appointments).
- Minimum availability standards are applied for specified inpatient and outpatient facility types for both M/S and MH/SUD (e.g., inpatient psychiatric facilities, SUD residential treatment, outpatient MH clinics).
ALL of the following
- Maryland Network Adequacy filings and operational analyses show median appointment waiting times below standards for both M/S and MH/SUD, with non-urgent MH/SUD care available sooner than non-urgent M/S care in the reviewed period.
ALL of the following
- Directory and online tools are used to support access and recruitment by making provider information searchable and by supporting provider outreach and verification processes.
Operational detail: specific numeric standards and monitoring cadence referenced in Maryland filings and COMAR requirements.
Access, adequacy, and directory criteria
Standards and practices governing member access to in-network M/S and MH/SUD services in Maryland.
ALL of the following
- Providers must meet Maryland appointment access timeframes: urgent care within 72 hours; routine primary care within 15 calendar days; preventive/nonurgent specialty within 30 calendar days; nonurgent behavioral health/SUD within 10 calendar days.
- These standards derive from COMAR and are applied equally to M/S and MH/SUD provider types.
ALL of the following
- Aetna conducts Maryland annual Network Adequacy filings and internal monitoring of availability and accessibility; analyses show networks for both M/S and MH/SUD met or exceeded minimum standards and median wait times were below standards.
- Interventions and recruitment efforts are applied comparably across M/S and MH/SUD and have demonstrable improvements for MH/SUD access from 2022 to 2023.
ALL of the following
- A single provider directory (online and paper) is maintained for both M/S and MH/SUD providers; the online directory is updated six days/week and the paper directory is updated quarterly; the directory includes specialties, facility types, language accessibility, and disability access information.
- Providers may notify Aetna of changes via a provider portal or online form; directory audits are conducted quarterly to verify accuracy.
ALL of the following
- The online directory is publicly accessible without an account and includes search/filter features (including MH-specific focus areas and facility types) to help members find appropriate providers; directory entries include information helpful for MH/SUD selection such as focus areas and services offered.
Operational practice: targeted proactive directory reviews and outreach calls are used to verify providers without activity at listed service locations and remove inactive locations.
Directory parity criteria
Aetna's assessment of parity between MH/SUD and M/S in directory practices.
ALL of the following
- Aetna applies the same inclusion criteria for provider directories for both M/S and MH/SUD — all contracted providers are listed and required legal information is included.
- Directory content includes MH/SUD-specific focus areas and service-level details (e.g., diagnoses, specialty focus) to aid member searchability; these additional fields are applied equally and do not restrict MH/SUD listings.
ALL of the following
- Operational features such as free-text search, categorical navigation (including a dedicated Mental Health category), and filterable focus areas provide equal or better search capability for MH/SUD compared to M/S services.
ALL of the following
- Maintenance procedures (quarterly provider prompts to verify information), targeted proactive directory quality reviews, outreach calls, and periodic directory audits are applied comparably to MH/SUD and M/S providers.
- 2023 directory audit results showed fewer MH/SUD inaccuracies compared to M/S and similar or higher proportions of MH/SUD providers accepting new patients, supporting operational parity.
ALL of the following
- Processes and strategies for directory design and maintenance are not applied more stringently to MH/SUD than to M/S services; members can search for and locate participating MH/SUD providers at least as easily as M/S providers.
The directory is available in Spanish and provides accessibility information and a web link under each entry to report incorrect provider information.
Coding, Codes Tables and Timelines
| Certain prescription drugs are covered under the medical plan when administered by a provider and may require precertification. |
| Place of service/inpatient status determined using National Uniform Billing Committee guidance for facility billing |
| Drugs categorized by tier: preferred generic, preferred brand, non-preferred brand and generic, preferred specialty, non-preferred specialty; coverage based on the drug guide with medical exception process. |
Provider Responsibilities, Precertification and Appeals
Identification of benefits requiring prior authorization
Please see Aetna's precertification lists (Aetna Participating Provider Precertification List, Aetna Behavioral Health Precertification List — together the National Precertification List (NPL)) for identification of medical/surgical and mental health/substance use disorder benefits that require prior authorization.
Precertification responsibilities and timelines
You need pre-approval (precertification) from Aetna for some covered services. Network providers are responsible for obtaining any necessary precertification before care is provided. For out-of-network care, the member is responsible for obtaining any required precertification. Timeframes and timelines for requesting precertification vary by urgency — see timelines block below. Emergency services do not require precertification, but notification is required as soon as reasonably possible.
- Network (in‑network) providers must obtain precertification for services on the Aetna Participating Provider Precertification List and Aetna Behavioral Health Precertification List (the NPL). Network providers cannot bill members for services solely because they failed to obtain precertification, though if a request is denied and the member elects care, the member may be financially responsible.
- Members (out‑of‑network) are responsible for obtaining precertification for services on the Member Precertification List (MPL) included in the certificate of coverage. Failure to precertify may reduce benefits or result in member liability; such unpaid amounts may not count toward the plan deductible or out‑of‑pocket maximum.
- To obtain precertification contact Aetna 24/7; representatives are available to accept requests from members, providers or facilities.
Services requiring precertification
Precertification is required for all inpatient admissions (medical/surgical and MH/SUD) except where specifically excluded (for example inpatient maternity and hospice). Precertification is also required for certain outpatient services and supplies as listed on the NPL and MPL. Examples include inpatient stays (hospital, rehabilitation, residential treatment for MH/SUD, hospice), and outpatient services such as complex imaging, comprehensive infertility services, cosmetic/reconstructive surgery, certain injectables and infusion drugs, kidney dialysis, many outpatient surgeries (e.g., outpatient back/knee/wrist surgery), sleep studies, non‑emergency air transport, and gene‑based, cellular and other innovative therapies (GCIT). Certain prescription drugs administered in a medical setting also require precertification.
- Inpatient examples: hospital stays, rehabilitation facility stays, residential treatment facility stays for MH/SUD, hospice facility stays, bariatric surgery, gender‑affirming treatment, GCIT.
- Outpatient examples: complex imaging, infertility services, cosmetic/reconstructive surgery, non‑emergency air transport, GCIT, certain injectables/infusions, kidney dialysis, outpatient back/knee/wrist surgery, sleep studies.
Precertification responsibility (in-network)
For in‑network benefits the participating provider is responsible for seeking precertification for services listed on the Aetna Participating Provider Precertification List and Aetna Behavioral Health Precertification List (the National Precertification List). There is no penalty to the member if precertification is not obtained by a participating provider; the network provider may not balance‑bill the member for failing to request precertification.
Precertification responsibility (out-of-network)
For out‑of‑network benefits, members are responsible for seeking precertification of services that appear on the Member Precertification List (MPL) included with the certificate of coverage. The MPL describes the consequences of failing to obtain precertification. Note: as of 01/01/2023, out‑of‑network outpatient MH/SUD services do not require precertification for members covered under Maryland‑sitused policies.
Inpatient precertification and urgency
All inpatient admissions (both medical/surgical and MH/SUD) are subject to precertification except for the limited exceptions noted (e.g., inpatient maternity and hospice). Aetna determines inpatient status using place of service guidance (National Uniform Billing Committee) and applicable law (including the Newborns' and Mothers Health Protection Act). For inpatient stays Aetna will communicate the precertified length of stay; any recommended extensions must be precertified and called in no later than the final authorized day.
- Inpatient precertification applies equally to M/S and MH/SUD admissions.
- For inpatient admissions, the facility, physician, or member must notify Aetna per the timelines; if additional days are recommended they must be submitted for review before the end of the authorized stay.
Timeliness standards and Maryland requirement
Timelines for precertification requests depend on urgency. Non‑emergency outpatient and scheduled admissions: call at least 14 days before the scheduled date. Urgent admissions: call before scheduled admission (treated as urgent when due to onset/change in illness or injury). Emergency admissions: notify Aetna within 48 hours or as soon as reasonably possible after admission. Approvals are generally valid for 180 days while the member remains enrolled. Maryland law requires non‑urgent precertification requests to be completed within 2 working days after receipt of information needed for review. Aetna applies NCQA timeliness standards and treats all inpatient MH/SUD admissions as urgent for timeline purposes.
- Non‑emergency scheduled care: call at least 14 days prior.
- Urgent admission: call before scheduled admission; treated with expedited/urgent timeline.
- Emergency admission: call within 48 hours or as soon as reasonably possible.
- Approvals typically valid for 180 days while enrolled.
- Maryland requirement: non‑urgent requests completed within 2 working days after receipt of needed information.
Medical exception and expedited request procedures
If a provider or member needs a medical exception for precertification, step therapy, quantity limits, or for a non‑formulary drug, requests can be submitted and may be expedited. Expedited coverage decisions are made within 24 hours. Providers may submit medical exception requests via the secure provider portal (Availity), by phone, fax, or mail to the Aetna Pharmacy Precertification/Medical Exception units. See Aetna contact resources for specific phone/fax numbers and addresses.
- Expedited medical exception decisions: within 24 hours.
- Submission methods: Availity provider website, phone, fax, or mail to the Medical Exception unit.
Non‑formulary coverage request review (Advanced Control)
Aetna reviewed non‑formulary coverage request data by formulary. For the Advanced Control formulary there were 363 total non‑formulary requests, 130 of which were for MH/SUD drugs; MH/SUD non‑formulary requests had a 34% approval rate versus 27% for medical/surgical drugs.
Non‑formulary coverage request review (Standard Opt Out)
For the Standard Opt Out formulary there were 6 total non‑formulary requests with 1 MH/SUD drug request (0% approval rate). For Med/Surg drugs on that formulary there was a 60% approval rate (3 of 5 requests).
Non‑formulary coverage request review (Exchange)
For the Exchange formulary there were 733 total non‑formulary requests, 183 of which were MH/SUD drug requests. MH/SUD non‑formulary requests had a 28% approval rate versus 19% for medical/surgical non‑formulary drugs.
Network provider not reasonably available
If an appropriate network provider is not reasonably available without undue delay, travel, or lacks the necessary training/expertise, members may obtain services from an out‑of‑network provider with prior approval from Aetna. Members must request approval before receiving such care; contact Aetna for assistance.
- Network provider not reasonably available allows prior approval for out‑of‑network care when lack of reasonable access would otherwise delay or prevent needed care.
- Member must obtain prior approval before receiving out‑of‑network services under this exception.
Provider directory verification and quality review
Participating providers are required to notify Aetna of changes to their practice information. Both medical/surgical and MH/SUD providers are prompted quarterly to verify directory information through Aetna's online provider portal. Aetna conducts targeted proactive directory quality reviews and quarterly audits; outreach is made to providers without recent activity at a listed location to verify whether listings should remain. Members can report inaccurate directory listings via a link in each listing; reports are reviewed and updated by Aetna's provider data services team.
- Quarterly provider prompts to verify practice/location/accepting new patients status.
- Periodic directory audits and targeted outreach to verify providers without activity.
- Mechanism for members to report inaccurate listings; updates handled by provider data services team.
Definitions and Reference Terms
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