Vice President for Health Initiatives Addressing the substance use disorder crisis nationally and in the states Strategies to improve enforcement of the mental health parity and addiction equity act Ellen Weber, JD Vice President for Health Initiatives Legal Action Center January 25, 2019

Parity Act Overview End historic health insurance discrimination against individuals with mental health and substance use disorders. October 2018 – 10th Anniversary. MH/SUD benefits, if covered, must be covered on the same level as medical/surgical benefits Most health plans must comply Large group (51+ employees) – fully insured and self-funded Exchange plans – individual and small group (50 or fewer employees - fully insured) Medicaid managed care organizations, Children’s Health Insurance (CHIP), Medicaid Alternative Benefit Plans Medicare not subject to the Parity Act

Parity Act General Standards Non-discrimination in all plan design features Out of Pocket Costs (Financial Requirements) Deductibles, co-payments, co-insurance, out-of-pocket maximums Numerical limits on treatment (Quantitative Treatment Limitations) Frequency of treatment, number of visits, days of coverage, days in a waiting period Limits on Scope and Access to Care (Non-Quantitative Treatment Limitations) Prescription Drugs Emergency Care

plan design features limiting access to and duration of treatment Benefit coverage/exclusions Medical management standards – medical necessity or appropriateness criteria Utilization management – prior authorization, concurrent or retrospective review Step Therapy Formulary design for prescription drugs and tiering Network tier design, provider admission standards, including credentialing and contracting standards Provider reimbursement rates and method for determining usual, customary and reasonable charges

Parity Act Non-Discrimination Standards Quantitative Features No separate or more restrictive FR or QTL for mental health and substance use disorder benefits than medical/surgical benefits. Non-Quantitative Features The “rules” for imposing and applying the 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 both as written and in operation.

Prescription Drug Benefit Non-Discrimination standards Single drug formulary with multiple tiers that apply different financial requirements if based on reasonable factors and not whether drug is used for a MH/SUD condition NQTLs apply to prescription drugs Drug exclusion Prior Authorization Step Therapy Tier placement Quantity Limits Other Limitations

Why important for Patients and Providers Benefit and Prescription Drugs Coverage + Continuum of Care Utilization management → limiting access to and delaying care Level of care decisions → limiting access to appropriate care Patient Access to Care and Affordable Care Network Adequacy Reimbursement Rates → higher use of out-of-network services for MH/SUD services and lower reimbursement of MH/SUD providers for same CPT codes (Milliman 2018)

Opportunities advocacy & enforcement Address benefit and prescription drug gaps and health plan design standards that affect access to SUD/MH services Parity Act can guide standard development Legislative, regulatory, Attorney General responses Adopt effective oversight and compliance strategies Complaint-centric process ineffective and impractical Pre-market compliance review and data auditing essential Consumer assistance needed for complaints

Legislative initiatives to Address Benefit GaPs and Access Barriers State Insurance Mandates: Ensuring continuum of care for SUD and MH coverage (hedge against ACA EHB revisions) – Ex: IL, MD, NJ, NY Limits on Prior Authorization for benefits and/or medications – Ex: DE, IL, MD, NY, NJ. Network Adequacy Standards: quantitative measures to regulate provider networks for SUD and MH providers Appointment Wait Times – CA, CO, ME, MD, TX, VT Geographic Criteria (travel time and/or distance) – CA, CO, DE, MD, MN, MO, NH, NJ, NV, VT, WA

initiatives to Address Oversight/Compliance Annual Compliance Reporting and Review Regulatory agency initiatives – CA (2014) Legislative mandate Private plans - IL and DE (2018) Medicaid – TN (2018) Annual Data Reporting and Analysis – CT, MA, TN (Medicaid), VT, NY (biennial beginning 2019) Ombud Program for Behavioral Health – CO, NY, TX Medicaid Managed Care Contracting – Parity Act compliance requirements and opportunity for data collection under contracts

Going forward Parity Act addresses key barriers to continuum of SUD/MH services and access to care. Current enforcement strategies not aligned with law’s framework and ineffective. Federal Guidance for Enforcement Department of Labor Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act and Frequently Asked Questions CMS Parity ComplianceTookit for Medicaid and Children’s Health Insurance Programs

Legal Action Center Parity Work LAC: A Guide to the Federal Parity Law NY Ombud Program - CHAMP Addiction Solutions Campaign: Parity Tracking Project: Making Parity A Reality Parity@10 Compliance Campaign – National and local advocates uniting to enhance enforcement of the Mental Health Parity and Addiction Equity Act. http://parityat10.org eweber@lac.org