Essential Benefits, Mental Health Parity & Medical Necessity 8560 West Sunset Boulevard Suite 500 West Hollywood CA Tel (310) Fax (888)

DISCLAIMER The following materials are intended for general education. Information provided herein is not an analysis of all applicable rules governing access to mental healthcare and is meant to be a starting point. Patients and providers challenging health plan denials of mental health or substance abuse benefits are encouraged to consult with counsel licensed to practice law within their respective jurisdictions. Psych-Appeal, Inc. is a California-based law firm and Meiram Bendat, JD MFT is licensed to practice law only in California.

Impediments to Coverage In general: insurer conflicts of interests Mental health: insurer discrimination – Bias against treatment for “poor choices,” “character traits” – Exploitation of shame, stigma, duress, lack of advocacy resources – Lack of “evidence”

The Promise of Reform Mental health parity – Federal (“MHPAEA”) Large group, fully-insured and self-funded health plans – State Piecemeal Affordable Care Act – Essential health benefits

Federal Mental Health Parity Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 – If MH and/or SA benefits are offered, then “treatment limitations” are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.

Federal Parity Rules Define “treatment limitations” to include: – Quantitative restrictions (“QTL”) Financial Duration – Nonquantitative restrictions (“NQTL”) Exclusions of levels of care Processes (ie. preauthorization, concurrent reviews) Fail-first, step-therapy Exclusions based on failure to complete a course of tx

State Mental Health Parity Comprehensive parity: Equal coverage of a broad range of mental health conditions, including substance abuse disorders. Broad-based parity: Equal coverage of a broad range of mental health conditions. May include some limitations or exemptions. Limited parity: Limits equal coverage to a specific list of mental health conditions and/or excludes equal coverage for significant policy groups and/or limits equal coverage to certain durational or financial limits or cost sharing requirements and/or allows plans to opt out of parity due to cost increase provisions. Mandated if offered: Requires that mental health overage be equal to other medical conditions if the plan offers mental health coverage. Mandated offering: Requires a plan to offer an option of mental health coverage that is equal to coverage for other medical conditions. Minimum mandated benefit: Mandates minimum mental health coverage that is not required to be equal to other medical conditions. Minimum benefit if offered: Requires a minimum benefit if the plan offers mental health coverage. Minimum benefit offering: Requires a plan to offer a minimum benefit.

Filling in the Gaps Federal law does not explicitly define “scope of services” under MHPAEA or ACA Still a state-by-state, plan-driven, or judicially- defined area So... – Make use of STATE law if at all helpful here Example, California law requires “all medically necessary treatment for severe mental illness”

From Despair to Parity But if state law is not helpful, then the BATTLE under MHPAEA is on – Discussion of NQTLs becomes operative Apples-to-apples? – Offerings/exclusions » Which medical/surgical benefits are offered by the plan(s) within the same classifications? – Medical management techniques » Preauthorization » Concurrent reviews

Medical Necessity Generally accepted standards of care are NOT necessarily the same as insurer- developed standards of care Insurer medical necessity guidelines must be scrutinized for deviations from generally accepted standards

Administrative Appeals Insurer denials MUST be challenged to preserve claimant rights to further remedies – Internal appeals, usually at least one ALWAYS necessary to exhaust all INTERNAL levels of appeal Providers generally Authorized Representatives for “urgent” claims/appeals under federal law External reviews by Independent Review Organizations – Offered through states for fully-insured claimants – Offered through insurers for self-funded plans

Preparation Obtain plan documents prior to admission – Summary Plan Description Employer-based – Certificate/Evidence of Coverage Insurer-based Obtain denial by fax Obtain behavioral health Designated Record Set – HIPAA Authorization Forms

Enforcement Regulatory enforcement depends on plan type – Self-funded (ie. large-group, private employer)  regulated by US DOL – Fully-insured (ie. individual, ACA-exchange, small group private or non-federal governmental employer)  regulated by states (primarily)  regulated by US HHS (secondary)