1 STATE & FEDERAL MENTAL HEALTH PARITY GUIDE Vera Oziransky, MPH Director of Research and Advocacy NAMI-NYC Metro 505 Eighth Avenue, Suite 1103 New York, NY 10018

2 TYPES OF COMPANIES Fully-Insured versus Self-Insured Companies: Fully-insured company-usually small companies (some exceptions are DOHMH, HHC). Purchase a package for employees from the health plan and pay the health plan to administer it. Self-insured company-usually larger companies (>200 employees). Design their own health benefits package and provide the health plan with a pool of money to administer it.

3 THREE CATEGORIES OF COMPANIES Fully-Insured Companies with < 50 employees. –Impacted by the New York State Mental Health Parity Law (Timothy’s Law). Fully-Insured Companies with > 50 employees. –Impacted by the New York State and Federal Mental Health Parity Laws. Self-Insured Companies –Impacted by the Federal Mental Health Parity Law.

4 The federal mental health parity law has extended the mental health benefits for employees of companies with > 50 employees. The Timothy’s Law coverage outlined in the next 6 slides applies only to employees of fully-insured companies with 50 employees. TIMOTHY’S LAW NEW YORK STATE’S MENTAL HEALTH PARITY LAW

5  Timothy’s Law became effective on January 1, 2007, and was made permanent in July, It is applicable to all contracts issued or renewed on or after that date.  The law requires fully-insured health insurance plans issued in New York State to provide a minimum level of mental health insurance benefits, and a degree of “parity” when compared to general medical insurance benefits.

6 TIMOTHY’S LAW NEW YORK STATE’S MENTAL HEALTH PARITY LAW Parity=Equality –Mental health parity=coverage for mental health services that is equal to the health plan medical coverage in terms of visits, days, deductibles, co-payments, and other cost- sharing mechanisms. –Timothy’s Law applies to out of network benefits as well. Thus, if an employee has a 20% coinsurance on out of network medical services, he/she cannot be charged 50% on out of network mental health services.

7 TIMOTHY’S LAW MANDATED MINIMUM MENTAL HEALTH COVERAGE All fully-insured businesses must provide a minimum of: 20 outpatient and 30 inpatient mental health days for all employees with “mental, nervous, or emotional disorders.” Co-payments, deductible rates, and other cost-sharing mechanisms for mental health services must not exceed those for any other medical services covered under the insurance plan.

8 FULL PARITY RIDER Employers with <50 employees can purchase a rider which will include the following benefit coverage: Full mental health parity for: –Adults and children with “biologically based mental illnesses” –Children with “serious emotional disturbances”

9 BIOLOGICALLY BASED MENTAL ILLNESS “Biologically based mental illness” is defined as: A mental, nervous, or emotional condition that is caused by a biological disorder of the brain and results in a clinically significant, psychological syndrome or pattern that substantially limits the functioning of the person with the illness. Biologically based mental illnesses covered are: schizophrenia/psychotic disorders, major depression, bipolar disorder, delusional disorders, panic disorder, obsessive compulsive disorders, bulimia, and anorexia.

10 CHILDREN WITH “SERIOUS EMOTIONAL DISTURBANCE” Are defined as individuals under the age of 18 years who have diagnoses of attention deficit disorders, disruptive behavior disorders, or pervasive development disorders, and one or more of the following behaviors: Serious suicidal symptoms or other life- threatening self-destructive behaviors Significant psychotic symptoms (hallucinations, delusions, bizarre behaviors) Behavior caused by emotional disturbance that placed the child at risk of causing personal injury or significant property damage. Behavior caused by emotional disturbance that placed the child at substantial risk of removal from the household.

11 THE MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (MHPAEA) The federal mental health parity law impacts self-insured and fully-insured companies with > 50 employees. Medicaid Managed Care Companies with < 50 employees who opt for the state-run exchange plans, available in Does NOT mandate mental health coverage. Does NOT mandate substance abuse coverage.

12 DOES MANDATE equality between mental health and medical/surgical coverage, if mental health coverage is provided, in regard to the following: –Financial requirements, such as deductibles and co-pays –Treatment limitations, such as number of mental health visits and hospital days covered –Out of network coverage –Standards for medical necessity determination. Reasons for any denial of benefits must be disclosed upon request THE MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (MHPAEA)

13 INTERACTION BETWEEN THE STATE AND FEDERAL MENTAL HEALTH PARITY LAWS Timothy’s Law mandates fully-insured companies to provide a minimum level of mental health coverage for most of the diagnoses covered by the DSM IV. The federal mental health parity law mandates full equality in coverage if mental health coverage is provided.

14 INTERACTION BETWEEN THE STATE AND FEDERAL MENTAL HEALTH PARITY LAWS Thus, for fully-insured companies-the federal parity law extends full parity coverage (outlined in federal regulations in slide 10) for most diagnoses covered in the DSM IV. –IE-Fully-Insured companies with > 50 employees MUST provide mental health coverage that is equal to medical/surgical coverage for most diagnoses covered in the DSM IV. Unfortunately, since self-insured companies are excluded from Timothy’s Law coverage, self-insured employers can choose whether to provide mental health coverage and what diagnoses to cover, if they do choose to provide coverage.

15 ADDITIONAL RESOURCES CMS "If you have concerns about your employer's plan's compliance with MHPAEA, contact our help line at extension or at Their description of the law with a link to the regulations that took effect July 1: tyAct.asp MENTAL HEALTH PARITY WATCH A link to the mental health parity watch site: Their /hotline info: "Send an to or call to leave a voice mail message."

16 ADDITIONAL RESOURCES NYS INSURANCE DEPARTMENT A link to the page containing the contact info for reaching the NYS Insurance department and their complaint form: "The Consumer Services Bureau employs a team of specially trained Agency Services Representatives (ASRs) to answer phone calls about New York insurance issues. Our ASRs can be reached Monday through Friday, 9AM to 5PM at , , or "

17 ADDITIONAL RESOURCES State guidance to health plans about complying with the federal law: State report with links to the published guidance to health plans about Timothy's Law: TL regulation: