Mental Health/Substance Use Disorder Parity

Mental Health/Substance Use
Disorder Parity: Improving Access
to Behavioral Health Care
JANUARY 25, 2014
About LAC and the Coalition for Whole Health
 Legal Action Center
 National law and policy organization that works to fight
discrimination against people related to substance use
disorders, HIV/AIDS, and/or criminal records
 Coalition for Whole Health
 A coalition of over 100 national, state, and local organizations
in the mental health and substance use disorder fields and
allied organizations working to ensure health reform is
successfully implemented for individuals with mental health
and substance use disorder needs
What We’ll Talk About Today
 What is the federal mental health (MH) and
substance use disorder (SUD) parity law?
 What should we look for to determine if coverage
meets parity requirements?
 What types of plans must comply with parity and
which agencies have oversight responsibilities?
 What do state-level advocates need to know about
Background of the Federal Parity Law
 The Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act (MHPAEA)
became Public Law 110-343 in October 2008
Eliminates certain forms of discrimination in insurance
coverage of MH/SUD benefits
Expands access to treatment for people with MH/SUD needs
 The requirements of MHPAEA were expanded in
2009 (CHIPRA) and 2010 (ACA)
Which Plans Must Meet Parity Requirements?
 Under federal parity law (MHPAEA) of 2008
 Large group employer funded plans
 Self-funded ERISA plans
 Medicaid managed care plans
 Under CHIPRA
 All CHIP plans
 Under the ACA
 All individual and small group Marketplace plans
 All non-grandfathered individual and small group plans
outside the Marketplaces
 Medicaid Alternative Benefit Plans (ABPs)
Limits of the Federal Parity Law
 The federal parity law does not
 Require large group plans to offer MH and SUD benefits
 Apply to certain plans (grandfathered individual and small
group plans, fee-for-service Medicaid, Medicare, or TriCare
 Certain plans can opt out
 Group health plans whose compliance with parity raises costs
by more than two percent in the first year and one percent
after that
 Non-federal government employers providing self-funded
group health plan coverage
Central Requirements of Federal Parity Law
 Parity prohibits most private health plans from
providing MH and SUD benefits in a more restrictive
way than other medical and surgical benefits covered
by the plan
 Requires comparison of plan coverage for MH and
SUD services and medications with coverage for
other illnesses
 Financial requirements and treatment limitations for
MH/SUD must not be more restrictive than what’s
applied to the plan’s medical/surgical coverage
Examining Parity Compliance
 The regulations identify six classifications of benefits
for purposes of parity analysis
Inpatient, in-network
Inpatient, out-of-network
Outpatient, in-network
Outpatient, out-of-network
Emergency care
Prescription drugs
 The final rule clarified that all MH/SUD services and
all medical/surgical services must be placed into this
framework for parity purposes
Parity Compliance: Financial Requirements
 Financial requirements applied to MH/SUD benefits
can’t be more restrictive than those applied to
corresponding covered medical/surgical benefits
Out-of-pocket maximums
 Prohibits separate cost-sharing requirements only
imposed on SUD or MH benefits
 Example: examine the copay for an outpatient session of
SUD treatment provided in-network with the copay for
an outpatient medical visit provided in-network
Parity Compliance: Treatment Limitations
 Parity requires examination of both quantitative and
non-quantitative treatment limits
 Quantitative treatment limits include
Day or visit limits
Frequency of treatment limits
 Separate treatment limits only imposed on SUD or MH
are prohibited
 Treatment limits applied to MH/SUD can’t be more
restrictive than those applied to corresponding
medical/surgical benefits
 Example: compare the number of days covered for
inpatient MH care with the number of days covered for
care in an inpatient medical facility
Parity: Non-Quantitative Treatment Limits
 Non-quantitative treatment limitations (NQTLs) are
often the most challenging to determine and most
rife with potential parity violations
 NQTLs are a plan’s medical management tools
Medical necessity criteria, utilization review, criteria to provide
or exclude a specific service
Prescription drug formulary design
Fail-first policies/step therapy protocols
Standards for provider admission into networks, and provider
Limits based on geography, facility type, provider specialty
Limits on scope or duration of benefits or services
Parity: Non-Quantitative Treatment Limits
 For NQTLs to meet parity requirements,
processes/factors used to apply limits to SUD or MH
benefits in a classification must be comparable to and
applied no more stringently than those applied to
medical/surgical benefits in the same classification
 Requires plan disclosure of detailed information about
how they manage both their MH/SUD and
medical/surgical benefits
Most plans subject to parity must
Disclose in writing how NQTLs are applied to their medical/surgical
and MH/SUD benefits
 During appeals, provide claimants with any additional evidence used
to make benefit determinations
 Disclose information within 30 days
Questions to Consider when Examining for Parity
 Is the plan a type that is required to comply with the federal
parity laws?
Does the plan cover MH and SUD benefits in all of the
classifications in which it covers medical/surgical benefits?
Are the financial requirements imposed on the MH or SUD
benefits more restrictive than those on corresponding
medical/surgical benefits?
Are the quantitative treatment limitations imposed on the MH
or SUD benefits more restrictive than those imposed on
corresponding covered medical/surgical benefits?
Are the non-quantitative treatment limits imposed on the MH
or SUD benefits more restrictive than those imposed on
corresponding covered medical/surgical benefits?
Parity Enforcement: Who is Responsible?
 Oversight and enforcement of the federal parity law
is shared by a number of federal and state agencies
State insurance commissioners have primary responsibility
over large and small group and individual market coverage
DOL and Treasury share jurisdiction over ERISA plans
HHS has primary authority over non-federal government
State Medicaid directors and CMS share jurisdiction over
Medicaid plans
 Interim final parity rule is in effect now for all plans
required to comply with parity and the final rule will
become effective for most plans in January 2015
Questions or for More Information
Dan Belnap
Legal Action Center
[email protected]
Coalition for Whole Health

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