The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that requires health insurers and group health plans to provide the same level of benefits for mental health and substance use disorder (SUD) services as they do for medical and surgical services. On March 29, 2016, the Centers for Medicare & Medicaid Services (CMS) published a final rule to apply certain provisions of the MHPAEA to Medicaid managed care organizations (MCOs), Prepaid Inpatient Health Plans (PIHPs) and Medicaid alternative benefit plans in states covering medical and surgical, mental health and SUD benefits under the State Plan (see 42 CFR Part 438 Subpart K, 42 CFR § 440.395, and 42 CFR § 457.496). The rule prohibits states, their MCOs and PIHPs from applying financial requirements and/or treatment limitations to mental health and/or SUD benefits in any classification that are more restrictive than those applied to medical and surgical benefits within the same classification.
In accordance with federal regulation at 42 CFR § 438.920, NC Medicaid requires NC Medicaid Managed Care Plans to submit information on treatment limitations applied to covered benefits to allow NC Medicaid to assess parity compliance when changes are made to covered benefits, treatment limitations or amendments to the NC Medicaid Managed Care contracts.
NC Medicaid completes the Mental Health Parity analysis across NC Medicaid Direct PIHP and NC Medicaid Managed Care. The analysis involves identification and analysis of limitations on all mental health, SUD and medical and surgical benefits offered to members. The findings of these analyses are summarized in MHPAEA Reports for Standard Plans, Behavioral Health and Intellectual/Development Disability (I/DD) Tailored Plans, NC Medicaid Direct and the Children and Families Specialty Plan, and are published on the Department’s new NC Medicaid MHPAEA website.
NC Medicaid analyzes treatment limitations applied to covered benefits in the following areas to determine compliance with MHPAEA requirements: utilization management (UM), medical necessity, provider admissions and credentialing, provider network and reimbursement, prescription drug authorization and formulary, and any other NC Medicaid Managed Care Health Plan-identified limitations.
As of Jan. 10, 2025, NC Medicaid has achieved operational compliance for the following plans, as demonstrated through NC Medicaid’s compliance with MHPAEA requirements:
Standard Plan, which launched July 1, 2021
NC Medicaid Direct PIHP, which launched April 1, 2023
Behavioral Health I/DD Tailored Plan, which launched July 1, 2024
Children and Families Specialty Plan, which launched Dec. 1, 2025
A determination of parity compliance for the following NC Medicaid Managed Care Plans is currently under CMS review:
Alternative Benefit Plan for the Expansion population, which launched Dec. 1, 2023.
Please visit the NC Medicaid Managed Care Health Plan Clinical Policy and Prior Authorization websites below for information on health plan prior authorization requirements and UM processes.
NC Medicaid Managed Care Plans’ Websites for Clinical Policy and Prior Authorization Information:
Standard Plan
- AmeriHealth
- Clinical Policy: https://www.amerihealthcaritasnc.com/provider/resources/clinical/policies
- Prior Authorization: https://www.amerihealthcaritasnc.com/provider/resources/physical-prior-auth
- Healthy Blue
- Carolina Complete Health
- United Healthcare
- WellCare
- Clinical Policy: https://www.wellcarenc.com/providers/tools/clinical-guidelines.html
- Prior Authorization: https://www.wellcare.com/North-Carolina/Providers/Authorization-Lookup
Behavioral Health I/DD Tailored Plan
- Alliance Health
- Partners Health Management
- Clinical Policy: https://providers.partnersbhm.org/service-definitions/#1755221929278-a11eac16-b473
- Prior Authorization: https://providers.partnersbhm.org/benefits/
- Trillium Health Resources
- Vaya Health
- Clinical Policy:
- Prior Authorization: https://providers.vayahealth.com/authorization-information/authorization-guidelines/
NC Medicaid Direct PIHP
- Alliance Health
- Partners Health Management
- Clinical Policy: https://providers.partnersbhm.org/service-definitions/
- Prior Authorization: https://providers.partnersbhm.org/benefits/
- Trillium Health Resources
- Clinical Policy: https://www.trilliumhealthresources.org/for-providers/clinical-practice-guidelines
- Prior Authorization: https://www.trilliumhealthresources.org/prior-authorization-services
- Vaya Health
- Clinical Policy:
- Prior Authorization: https://providers.vayahealth.com/authorization-information/authorization-guidelines/
Children and Families Specialty Plan
- Healthy Blue Care Together
Related Links
Contact
NCTracks Call Center: 800-688-6696
For questions related to NC Medicaid Managed Care, contact the health plans for more information. Contact information is available on the Health Plan Contacts and Resources webpage.