Mental Health & Addiction Parity: Getting What is Rightfully Yours for Mental Health & Substance Abuse Care

Agenda Welcome What is parity? Signs of parity problems Stories: parity problem or not? How to complain Practice filing a complaint Wrap-up Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

What is Parity? In health insurance, parity means… Mental health or substance abuse care must be covered by health insurance at the same level as other types of medical care in terms of: Treatment limits (like number of visits, hospital days) Out of pocket costs (like deductibles or copays) Review for treatment approval

Parity is required by federal law 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 Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

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 Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Large employer sponsored health plans 50+ employees Includes self-insured Medicaid managed care plans Does not require plans to offer mental health (MH) or substance use disorder (SUD) benefits, but… If a health plan covers MH/SUD, then benefits must be at the same level as for other types of medical care. Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

Patient Protection and Affordable Care Act of 2010 (ACA) Consumer protections Medicaid based on income to 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 Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

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. Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

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 Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

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 and unchanged Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

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* Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement * Health plans must provide medical necessity criteria to their members upon request.

Signs that a health plan may not be following parity law… Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

than for medical or surgical care Fewer visits for MH/SUD care than for medical or surgical care Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

Residential or intensive MH/SUD treatment The health plan Residential or intensive MH/SUD treatment not covered but covered for other conditions Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

than for medical or surgical care Higher costs for MH/SUD care than for medical or surgical care Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

as not ‘medically necessary’ MH/SUD care denied as not ‘medically necessary’ but health plan does not share standards used to decide Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

Having to ask permission to get MH/SUD care covered, more than for other health conditions Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

but can for other health care Can’t find MH/SUD in-network providers but can for other health care Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

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

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

How to Complain Talk with your MH/SUD provider Contact your health plan customer service office Not resolved? File a complaint with your health 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

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 Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement

Sample Mental Health Story 38-year-old married woman, covered by husband’s small group employer-sponsored plan “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? Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement * TMS: Transcranial Magnetic Stimulation is used for treatment-resistant depression

Sample Addiction Story A 45-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 “I’m trying to recover from a heroin habit that started after my dentist prescribed oxycodone for oral surgery. My addiction counselor wants me to take Suboxone, but it’s a tier 3 drug in my health plan. I’d have to pay $120 every month. Why am I paying such high premiums if they won’t cover the care I need?” Does this story have parity issues? If so, what? What is the first step he should take? What government agency should he contact? 14

Complaint & Appeal Form Standard Insurance Consumer Complaint form Developed by National Association of Insurance Commissioners (NAIC) Filing a complaint is quick, simple … and important

Kennedy Forum Complaint Portal Substantially All - applies to 2/3 of benefits within a given classification Predominant – applies to more than half of type of limit or requirement Collects stories for advocacy We need your voice! www.parityregistry.org

Consumer Resources Tennessee: Dept. of Commerce & Insurance: 615-741-2241 TennCare Advocacy Program: 800-758-1638 Dept. of Mental Health and Substance Abuse Services: 800-560-5767 Federal: Department of Labor (DOL) EBSA: 1-866-444-3272  CMS: 877-267-2323 SAMHSA: 877-726-4727 Advocacy Organizations: NAMI: www.NAMI.org/parity ParityTrack: www.paritytrack.org Community Catalyst: www.communitycatalyst.org Depression Bipolar Support Alliance (DBSA): www.dbsalliance.org

Tennessee Parity Project Bonnie Hannah Manager of Advocacy & Communications bhannah@namitn.org

Name Organization name@email.org Thank you! Questions? Name Organization name@email.org