for Advocacy Parity: Fairness in Health Coverage NAMI Smarts for Advocacy Parity: Fairness in Health Coverage Module Five NAMI Smarts for Advocacy Rev June 2017 © NAMI, Inc. 2013

Agenda Welcome What is parity? Signs of parity problems How to complain Stories: parity problem or not? Practice filing a complaint Wrap-up 3

Ground Rules Participate fully Help keep us on time To help everyone get the most out of this training, we ask you to agree to the following: Participate fully Help keep us on time Turn off cell phones 2

What is Parity? Mental health or substance use treatment must be covered by health insurance at the same level as other types of medical care: Treatment limits Out of pocket costs Review for treatment approval 4

for most types of health plans It’s the law of the land Parity is required by federal law for most types of health plans 5

Major Parity Laws Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) The Patient Protection and Affordable Care Act of 2010 (ACA) 21st Century Cures Act of 2016 6

Mental Health Parity & Addiction Equity Act (MHPAEA) Large employer sponsored health plans 50+ employees Includes self-insured Medicaid managed care plans Does not require plans to offer mental health or addiction treatment benefits, but… If covered, then benefits must be at the same level as for other types of medical care. 7

Patient Protection & Affordable Care Act (ACA) Consumer protections Medicaid eligibility: 138% of poverty Extends parity to: All individual and small group health plans Medicaid expansion alternative benefit plans Children’s Health Insurance Plans (CHIP) Insurance Exchanges/Federal Marketplace 10 essential health benefits (EHB) – Includes MH/SUD benefits – All EHB categories must meet parity 8

WHY is Parity still a Problem? Writing the rules took years. Final MHPAEA rules were issued: 2013 for private insurance 2016 for Medicaid/CHIP Federal and state oversight is complicated and unclear Health plans must make profits for stakeholders. They take advantage of loopholes, gray areas and lack of enforcement. 9

21st Century Cures Act Broad research & health service law Enforces parity: Guidance on how plans should comply Meeting to improve federal/state parity enforcement Annual report on parity complaints Government Accountability Office (GAO) study Non-quantifiable treatment limits (NQTL) How to improve enforcement Resources on parity for eating disorder treatment 10

MOST Health Plans must Meet Parity, Except… Medicare Medicaid fee for service State and local government plans Faith-based health plans Retiree only plans Tricare Grandfathered plans Small group (2 – 50 employees) Individual Purchased before 2010 & unchanged 11

What must be at the same level? Inpatient care: In-network Out-of-network Outpatient care: Residential treatment Emergency care Prescription drugs Co-pays Deductibles Out-of-pocket cost limits Providers in local area Facility type Provider payment rates Standards used to approve or deny care* 12

Signs that a health plan may not be following parity law… 13

than for medical or surgical care Fewer visits for MH/SUD care than for medical or surgical care 4

residential or intensive Doesn’t cover residential or intensive MH/SUD treatment but does for other conditions 4

than for medical or surgical care Higher costs for MH/SUD care than for medical or surgical care 4

as not ‘medically necessary’ MH/SUD care denied as not ‘medically necessary’ but health plan does not share standards used to decide 4

Having to ask permission to get MH/SUD care covered, more than for other health conditions 4

but can for other health care Can’t find MH/SUD in-network providers but can for other health care 4

Got a Parity Problem? SPEAK UP! Complaints and appeals help you get the care you have a right to under parity law …and make the law stronger for everyone 4

Consumer complaint service Start with your state department of insurance Consumer complaint service 4

How to file a complaint Talk with your MH/SUD provider Contact the health plan customer service office Not resolved? File a complaint with your plan Contact the government* For information For help filing a complaint with the health plan To file a complaint if not satisfied with health plan * See chart in handout 4

Not sure where to complain? Federal HHS parity complaint website www.hhs.gov/mental-health-and-addiction-insurance-help Information Links: Federal agencies State insurance departments 4

Sample Story 1 Listen to a personalized email Listen to a quick email 59-year-old man with an individual health plan purchased through the state health insurance exchange Listen to a personalized email Listen to a quick email Notice the impact of just a few lines “My brand name diabetes medication is on tier 1 with no coinsurance, but my mental health medications are on tier 3 and I can’t afford $240.00 out of pocket every month. I have to ‘step up’ by taking less expensive psych meds for 6 weeks. I only get the one I need if the other doesn’t work. I changed health plans twice before and had to ‘step up’ each time. Why can’t they look at my record and approve the right drug from the start?” Does this story have parity issues? If so, what? What is the first step he should take? What government agency should he contact? 14

Sample Story 2 Listen to a personalized email Listen to a quick email 38-year-old married woman, covered by husband’s small group employer-sponsored plan Listen to a personalized email Listen to a quick email Notice the impact of just a few lines “My health plan requires prior authorization for mental health, but not for medical care. The doctor prescribed TMS * for my depression, but my health plan denied the service as ‘not medically necessary’ despite the fact that I’ve tried everything.” Does this story have parity issues? If so, what? What is the first step she should take? What government agency should she contact? 14

Sample Story 3 Listen to a personalized email Listen to a quick email 20 year old single woman with Medicaid managed care. Her mother is speaking: Listen to a personalized email Listen to a quick email Notice the impact of just a few lines “Our Managed Care Organization (MCO) evaluated medical necessity for day hospital treatment almost on a daily basis. That made no sense because the decision to admit our daughter to this type of treatment was based on her receiving residential care for four weeks. Care was denied several times while she was there and it was a constant struggle to extend the stay. I don’t understand why this is different than her stay in the rehab facility after she broke her leg.” Does this story have parity issues? If so, what? What is the first step he should take? What government agency should he contact? 14

Practice filing a complaint Now it’s your turn… Practice filing a complaint In pairs: One person plays the member The other is the provider Situation: A request for individual therapy for PTSD has been denied. The health plan requires group therapy first, but the member is nervous around strangers. Complete the state health insurance complaint form together. 15

Congratulations! What did you learn? How will you use it? 25

Kennedy Forum Complaint Portal Collects stories for advocacy We need your voice! www.parityregistry.org 4

Consumer Resources State: Federal: Advocacy Organizations: State Insurance Authority Medicaid Complaints State Mental Health Authority Federal: Department of Labor (DOL) EBSA: 1-866-444-3272  CMS: 877-267-2323 SAMHSA: 877-726-4727 Advocacy Organizations: Depression Bipolar Support Alliance (DBSA): www.dbsalliance.org Mental Health America: www.mentalhealthamerica.net NAMI: www.NAMI.org/parity ParityTrack: www.paritytrack.org 26

Please turn in your evaluation form We value your feedback Please turn in your evaluation form 26

Authors Angela Kimball, NAMI Sita Diehl, NAMI National Director of Policy and Advocacy Sita Diehl, NAMI Director, State Policy & Advocacy 27 © NAMI, Inc. 2013