Implementing and Monitoring Parity Mady Chalk, Ph.D, MSW Dir., Policy Center Treatment Research Institute May, 2014 ©Treatment Research Institute, 2013

A Very Brief Review of Parity (MHPAEA) Requires group plans and insurers to ensure that financial requirements and treatment limitations applicable to benefits for treatment of mental health and substance use disorders are no more restrictive than the predominant requirements or limitations applied to substantially all med/surg benefits. MHPAEA DOES NOT MANDATE THAT A PLAN PROVIDE MH/SUD BENEFITS

A Very Brief Review of Parity (MHPAEA) “Financial requirements”=deductibles, copays, coinsurance, out of pocket limits “Treatment limitations”= frequency of treatment, number of visits, days of coverage, other limits on scope or duration of treatment

A Very Brief Review of Parity (MHPAEA) “Predominant/substantially all” financial test applies to six classifications of benefits one-by-one: Inpatient in-network Inpatient out-of-network Outpatient in-network Outpatient out-of-network Emergency care Prescription drugs

A Very Brief Review of Parity (MHPAEA) Applies to plans sponsored by private and public sector employers with more than 50 employees and to health insurers who sell plans to those employers Individual market plans Medicaid managed-care plans CHIP Medicaid Alternative Benefit Plans and Benchmark Equivalent Plans

A Very Brief Review of Parity (MHPAEA Small Employer Exemption=employers with <50 employees Transparency – medical necessity determinations for current or potential participant, beneficiary or contracting provider upon request; reasons for denial of reimbursement or payment

A Very Brief Review of Parity (MHPAEA Copays and Deductibles While plans can no longer have separate deductibles, they do have flexibility in how they choose to combine these deductibles As long as there is no separate deductible that applies only to MH/SUD benefits, the plan can set the combined deductible at whatever amount it chooses

A Very Brief Review of Parity (MHPAEA) NQTLs “Quantitative limits (QLs) and non-quantitative limits (NQTLs) are subject to the same test as financial requirements for each class of benefits NQTLs= medical management standards, formulary design, usual/customary/reasonable amounts have a separate parity requirement

A Very Brief Review of Parity (MHPAEA Provider Networks Provider network enrollment criteria must be substantially similar for behavioral health providers and for health providers Enrollment criteria may include: Geographic distribution within a service area Area’s population density Time and/or distance to access physicians Location of low-income, medically underserved population Need/demand analyses

A Very Brief Review of Parity (MHPAEA Provider Networks Different co-payment rates may apply to services provided by in-network and out-of-network providers Value-based or tiered provider networks may be used e.g., providers that are cost efficient or of “higher quality” may be placed in preferred tiers Health plans MUST ensure they contract with enough providers to ensure sufficient access and choice

A Very Brief Review of Parity (MHPAEA) Out-of-Network Benefits – if plans offer med/surg out-of-network benefits must offer MH/SUD benefits on the same basis Enforcement: DOL and IRS for ERISA; HHS for self-funded non-Federal gov’t plans; State insurance commissioners for large group market; to date no Federal funds have been allocated to enforcement

Now to The Issues We Need to Monitor NQTLs NQTL Transparency – Can one determine the processes, strategies, evidentiary standards being used for MH/SUDs and for med/surg conditions Is information publicly available, available to plan enrollees, participating providers, easy to obtain upon request, considered proprietary, behind a firewall, hard copy only or on the Web, by mail upon request in a timely fashion, one document or many

Now to The Issues We Need to Monitor NQTLs - Behavioral Health Criteria Are the evidentiary standards clearly specified or do they leave room for interpretation; is there an evidence base; how do they compare with med/surg Type of service Prior Authorization Sources of criteria e.g., ASAM Criteria Role of clinical judgment by UR personnel Criteria counter to evidence “Vague” or open to major interpretation

Now to The Issues We Need to Monitor Costs What percent of individuals have unmet MH/SUD needs based on costs e.g., copays, deductibles How do out-of-pocket costs for MH/SUD services compare to other medical services How do cost-sharing requirements for medications compare

Now to The Issues We Need to Monitor Provider Networks for Behavioral Health Regulations – what are they and how is compliance monitored and enforced Network Development – What are the criteria/credentialing requirements for provider participation, do insurers provide incentives to develop larger networks, how is client need/demand for services taken into account in design of networks, how are access barriers or unmet need monitored, do designs include the full range of services  

Now to The Issues We Need to Monitor Provider Networks for Behavioral Health Network Transparency – can enrollees easily determine which providers are in-network, is information accurate Characterization – what do networks look like compared to networks for physical health providers e.g., number, availability, percent included in an area Network Adequacy – evidence that networks meet need and demand for behavioral health services

Now to The Issues We Need to Monitor Provider Networks for Behavioral Health Size – how does the size of behavioral health provider networks compare with networks for other medical conditions Scope of services - Whether and to what extent does parity implementation address the “scope of services” or “continuum of care” under group health plans or health insurance coverage

Report Cards Insurance Complaints Use of preauthorization for behavioral health For all services, for inpatient only as for other medical conditions Step therapy protocols Covering treatments “conditional” on requirements for participation in other care

Report Cards To what extent do patients have difficulty finding an in-network behavioral health provider Do medical management criteria result in claim denial rates that are significantly different for med/surg and behavioral health conditions How are recognized clinically appropriate standards of care being used relative to NQTLs

Evaluation and Research Impact of Parity Baseline against which to measure: Good and Modern Addictions and Mental Health Service System Coverage and Benefits for Other Chronic Illnesses and for Med/Surg Conditions Intentions Under the Final Rule

Evaluation and Research Impact of Parity Under parity how do MH/SUD readmission rates to the same or higher levels of care change Under parity, how does ER use change, what combination of services produces that result Do providers experience fewer patients entering treatment based on costs – deductibles and co-pays

Evaluation and Research Impact of Parity State Spending – how does State spending change by source Provider Revenues – how do the sources of provider revenues change e.g., private, public (block grant, Medicaid), How does reimbursement affect coverage How does coverage affect utilization

An Important Note The evaluation and research that can be carried out now is related to commercial health plans THE FINAL RULE FOR MEDICAID MANAGED CARE PLANS HAS NOT BEEN WRITTEN