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Employee Benefits Security Administration

Model Forms Under MHPA

Notice of Group Health Plan's Exemption from the Mental Health Parity Act

This notice must be provided to you under the requirements of the Mental Health Parity Act of 1996 (MHPA) because the group health plan identified below is claiming the one percent increased cost exemption from the requirements of MHPA. Under MHPA, a group health plan offering both medical/surgical and mental health benefits generally can no longer set annual or aggregate lifetime dollar limits on mental health benefits that are lower than any such dollar limits for medical/surgical benefits. In addition, a plan that does not impose an annual or aggregate lifetime dollar limit on medical/surgical benefits generally may not impose such a limit on mental health benefits. However, a group health plan can claim an exemption from these requirements if the plan's costs increase one percent or more due to the application of MHPA's requirements.

This notice is to inform you that the group health plan identified below is claiming the exemption from the requirements of MHPA. The exemption is effective as of the date below. Since benefits under your group health plan may change as of the date below.  It is important that you contact your plan administrator or the plan representative identified below to see how your benefits may be affected as a result of your group health plan's election of this exemption from the requirements of MHPA.

Upon submission of this notice by you (or your representative) to the plan administrator or the person identified below, the plan will provide you or your representative, free of charge, a summary of the information upon which the plan's exemption is based.

Notice of Group Health Plan's Exemption From the Mental Health Parity Act

Group Health Plan Name: Plan Number:
Plan Administrator: Address:
City:
Telephone Number: State:
Zip Code:

For Single-Employer Group Health Plans

Employer Sponsoring Plan: Employer Identification Number:
Telephone Number: Address:
City:
Effective Date of the Exemption: State:
Zip Code:

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Notice of Group Health Plan's Use of Transition Period

This notice must be provided if a group health plan uses the transition period under the requirements of the Mental Health Parity Act (MHPA). Under MHPA, a group health plan offering both medical/surgical and mental health benefits generally can no longer set annual or aggregate lifetime dollar limits on mental health benefits that are lower than any such dollar limits for medical/surgical benefits. In addition, a plan that does not impose an annual or aggregate lifetime dollar limit on medical/surgical benefits generally may not impose such a limit on mental health benefits. However, a group health plan can claim an exemption from these requirements if the plan's costs increase one percent or more due to the application of MHPA's requirements. Under MHPA, a plan that claimed the one percent increased cost exemption prior to the issuance of the MHPA interim regulations based on assumptions inconsistent with the MHPA interim regulations may delay compliance with the parity requirements of MHPA until a date no later than March 31, 1998.

This notice is to inform you that the plan is utilizing the MHPA transition period and that the plan is delaying compliance with the parity requirements of MHPA until a time no later than March 31, 1998.

Notice of Group Health Plan's Use of Transition Period

Group Health Plan Name: Plan Number:
Plan Administrator: Address:
City:
Telephone Number: State:
Zip Code:

For Single-Employer Group Health Plans

Employer Sponsoring Plan: Employer Identification Number:
Telephone Number:  Address:
City:
Signature of Plan Administrator: State:
Date: Zip Code: