Tuerk Conference, Baltimore, MD April 20, 2018 The Mental Health Parity and Addiction Equity Act @ 10: Achieving Non-Discriminatory Access to Care Tuerk Conference, Baltimore, MD April 20, 2018

Presentation Highlight Parity Act Standards Identify Enforcement Barriers Identify Strategies to Improve Parity Enforcement Identify Treatment Barriers and Parity “Fixes” Advocacy Opportunities - Parity at 10 Maryland Campaign

Parity Act – Equal Insurance Coverage Mental Health Parity and Addiction Equity Act (2008) (Parity Act) End historic health insurance discrimination against individuals with mental health (MH) and substance use disorders (SUD) 10th Anniversary – How to achieve the promise of the law? Parity at 10 Maryland Campaign

Parity Act – Equal Insurance Coverage Plans that provide MH/SUD benefits must cover them “equally” (at “parity”) with medical/surgical benefits Equal benefit coverage Equal access to benefits Parity Act does not require plans to cover MH/SUD benefits, but many other laws do Affordable Care Act – Essential Health Benefits Maryland law mandates benefit coverage for SUD and MH

Maryland Mandated Benefits and Parity Mandates Insurance Coverage Maryland Mandated MH/SUD Benefits Federal Parity Law Individual ✔ Small Group (100 or fewer employees) ✔ ACA Plans – 50 or fewer employees Large Group (101+ employees) Public Employer (self-insured) ✔ State/local plans may opt out Medicaid (MH/SUD carve-out but enrollees receive MCO medical services) Medicaid Expansion population Children’s Health Insurance Program (CHIP) Describe the full scope of benefits under state law and the new standards for prescription drugs to treat OUD

Cost Sharing “Equality” Required Deductibles ($5,000/individual) Co-payments ($30/visit) Co-insurance (20% reimbursed amount) Out-of-Pocket Maximums Cost Sharing “Equality” Required Financial Requirements – Parity Act

Limits on Length of Care Number of visits (15 outpatient visits/year) Days of Coverage (14 days residential treatment) Frequency of Treatment (2 episodes of care/year) Limits on Length of Care “Equality” Required Quantitative Treatment Limitations

Limits on Scope and Access to Care Covered SUD/MH benefits (excluded benefits) Medical Necessity Criteria Prior authorization and continuing care requirements Step therapy and fail first Prescription drugs Network adequacy and provider admission to networks Provider reimbursement “Equality” Required

Barriers to Substance Use and Mental Health Care Parity Act Violation? Limited Network Providers Benefit Limits & Exclusions Burdensome Prior Authorization Barriers to Substance Use and Mental Health Care

Parity Act: Non-Discrimination Standard Out-of-Pocket Costs and Limits on Length of Treatment Standard In Practice No separate or more restrictive financial requirements or quantitative treatment limitations for mental health and substance use disorder benefits than medical/surgical benefits Separate – must also apply to 2/3 of medical/surgical benefits More Restrictive – value must apply to 51% or more of the medical/surgical benefits Most Plans Comply Mathematical test - easily applied Compliance review – easy to identify differences and verify through plan data

Parity Act Non-Discrimination Standard Other Plan Features Limiting Access to Treatment Standard In Practice The “rules” for imposing and applying a non-quantitative treatment limitation (NQTL) on the MH or SUD benefit must be comparable to and applied no more stringently than the rules for imposing and applying the NQTL on medical/surgical benefits Rules as “written” Rules in “operation” Plans do not comply Requires detailed comparative analysis of virtually all “rules” for coverage of and access to SUD and MH benefits and medical benefits Requires data analysis to show “no more stringent” application

Network Access and Reimbursement 31% of MH/SUD office visits out-of-network v. 3% medical visits out-of-network – Maryland 3rd worst in U.S. (2015) Rate of disparity for out-of-network use of MH/SUD providers for inpatient, outpatient facility and office visits increased over 3 years (2013-15). Primary care providers received 27.6% higher reimbursement than MH/SUD providers for same or similar billing codes (2015) Network Access and Reimbursement Milliman Report Addiction and Mental Health v. Physical Health: Disparities in Network Use and Provider Reimbursement Rates in Maryland Example of what one would do to address as a parity act violaton Data 2013-2015 - 3 year period

Transparency – Information Plans Must Disclose Medical Necessity Criteria – both MH/SUD and medical (patient and provider) Reasons for any denial of coverage or reimbursement (patient) Parity compliance documents (patient or provider as authorized representative) Insurer cannot withhold plan documents based on proprietary information

Barriers to Parity Act Enforcement

Enforcement Obstacles: Regulators Don’t get plan information needed to evaluate parity compliance before the plan is approved for sale. Cost-sharing - can usually identify problems NQTLs – not identified and compliance information not provided Investigation strategies – time consuming (market conduct surveys have taken 18 -20 months) and delay fixing violations

Enforcement Obstacles: Consumers Don’t receive complete information about benefits, medical necessity and care authorization or Parity Act Rights Don’t receive plan information when requested Unable to conduct complex analysis, particularly in a crisis Individual complaints do not address systemic plan violations

Improve Parity Enforcement Fix benefit and prescription drug gaps and plan features that limit access to SUD/MH services Parity Act can guide standard development Legislative and regulatory responses

Adopt effective oversight and compliance strategies Plans must prove parity compliance before allowed to sell plan Data auditing – Insurance Dept. and Medicaid

Fix Benefit and Prescription Drug Gaps Maryland Initiatives Commercial Insurance Comprehensive Benefit Coverage (HB 1127/SB 968) (2017) Remove Prior Authorization Medications for Opioid Use Disorders (HB 887) (2017) Network Adequacy Regulations (2017) Medicaid Medicaid Parity Compliance (HB 1217/HB 899) (2016) Regulations – telehealth, programs bill physician services (2016-2017) 1115 Waiver – SUD 3.3, 3.5, 3.7 Benefit Coverage – residential treatment, IOP, diagnostic evaluation, opioid treatment services, medication evaluation and management PA – methadone, buprenorphine and naltrexone NA regulatons – in effect as of Dec. 31, 2017 – Travel Distance (urban, suburban and rural); wait times – urgent, non-urgent MH/SUD and routine medical

Adopt Effective Oversight and Compliance Strategies Maryland Initiatives Commercial Insurance Parity Compliance Report (HB 1010/SB 586) (2015 - failed) 3rd Market Conduct Survey – Carrier Data (due July 2018) Network Access Report (annual) Medicaid Parity Compliance Report (Due Oct. 2, 2017 and pending) Identify data from the 3rd MCS -

Maryland Parity at 10 Campaign 10 States (3 years) – address key barriers to accessing SUD/MH services through robust Parity Act enforcement. Maryland – 1 of 5 launch states (IL, NJ, NY, OH) National and local advocates uniting to achieve equity through education and advocacy. Establish more effective compliance standards – Plans prove parity compliance before sold

Key Barriers Commercial Insurance Network Adequacy Provider Gaps → Unaffordable Out- of-Network Care Reimbursement, Contracting, Credentialing Requirements Limited Access to Residential Treatment (authorization standards) Billing Restrictions for Program Physicians under BHO Contracts Complaint Process Ineffective and Burdensome Key Barriers Commercial Insurance Others to add to this List?

Key Barriers Medicaid Prior Authorization Requirement Reimbursement Limitations – Multiple Services Single Day Benefit Exclusions – some SUD Benefits Rate Structure – SUD Benefits Key Barriers Medicaid Others to add to this list?

Parity Enforcement: Challenge Barriers to Care Identify Barriers Interfering with Delivering of MH/SUD Care in Practice Report to regulators Ask for parity analysis and document disclosure – are rules for SUD/MH benefits comparable to rules for Med/Surg benefits (as written and in operation) and are requirements imposed more stringently on SUD/MH benefits Patient – Benefit Exclusions and Level of Care Denials File complaint with carrier and submit to regulators Ask for parity analysis and disclosure of documents What you can do as an individual – in your practice. 1st – network admission denials; burdensome requirements; reimbursement rates – low and can’t negotiate; contract standards – seem burdensome’ prior authorization requirements – for all services or concurrent review too frequent.

Parity Enforcement: Remove Barriers to Care Education – Providers, Consumers and Policy Makers Legislative and Regulatory Advocacy Annual Data Gathering: identify disparities between MH/SUD and med/surg decision-making that could reflect underlying Parity Act violation Prospective, pre-market demonstration of parity compliance Streamline reporting of carrier practices and access problems to regulators

Achieving the Parity Act’s Promise Your Suggestions Join Parity at 10 Education and Advocacy Work

Ellen Weber eweber@lac.org 202-544-5478 Ext. 307