Mental Health Parity Final Rule May 18, 2016

Mental Health Parity Financial and treatment limitations on Mental Health and Substance Use Disorder benefits may be no more restrictive and applied no more stringently than to Medical/Surgical benefits

Financial Limitation Analysis Lifetime and Annual Dollar Limits o Limits on <1/3 of Med/Surgical benefits  No limits permitted on MH/SUD benefits o 1/3-2/3 of Med/Surgical benefits  Average of Med/surgical limitations o >2/3 of Med/Surgical benefits  Apply the limit to MH/SUD without distinguishing between services or  Include a limit on MH/SUD no more restrictive than on Med/Surgical Cumulative Financial Requirements o No Separate limits

Quantitative Treatment Limitations (QTLs) Non-Quantitative Treatment Limitations (NQTLs) Classifications o Inpatient o Outpatient  Office Visits  All other outpatient o Emergency o Pharmacy  Can use tiered list Treatment Limitation Analysis

Quantitative Treatment Limits Quantitative Treatment limits include visit limits, inpatient day limits, and co-pays Must apply to substantially all (2/3) Medical/Surgical benefits MH/SUD limit must be equal to or less restrictive than the predominant limit

Inpatient o Limited to 30 days for Med/Surgical o Limited to 30 days for MH/SUD Outpatient o Specialist services limited to 50 visits (Med/Surgical) o PCP services are unlimited (Med/Surgical) o Physical Therapy visits limited to 20 visits o Occupational Therapy limited to 20 visits o Outpatient MH Services limited to 20 visits Emergency Services o Unlimited for both Table 1—Example of Quantitative Treatment Limit Benefit/classification —Medical/Surgical Projected payment Percent of total costs Percent of classification subject to a limit Inpatient Hospital$400x100 Inpatient total400x100 Physician Services150x270 Specialist Services250x46 Physical Therapy75x13.5 Occupational Therapy75x13.5 Outpatient total550x10073 Emergency Services100x1000 Emergency total100x1000 Quantitative Treatment Limits

Non-Quantitative Treatment Limits NQTLs include medical management standards, formulary design, network tier design, provider admission and reimbursement rates, fail-first policies, and out-of-network access standards May not include NQTLs unless comparable standards are applied to medical/surgical benefits in the same category. NQTL standards may not be applied more stringently to MH/SUD benefits NQTL evaluation focuses on equal processes not necessarily equal outcomes

Non-Quantitative Treatment Limits Ex: MCO requires PA for all inpatient benefits. In practice, med/surgical benefits are routinely approved for 7 days while MH/SUD benefits are routinely approved for 1 day Ex: MCO applies concurrent review to inpatient care where high levels of variation (CV>.8) are present. In practice, this standard impacts 60% of MH/SUD benefits and 30% of Medical/Surgical benefits

Other Parity Provisions Availability of Information No Cost Exemption o Costs to be incorporated into cap. rates IMD Exclusion

Potential MCO Impacts Contracts will need to comply with mental health parity before October 2, 2017 Information and data necessary to perform the parity analysis (QTLs, NQTLs, Annual financial limitations)

Thank You.