Let’s Go Back to the Basics MHPAEA 101 – HEALTH TRACK Jo-Anne Fameree, Risk & Regulatory Consulting Irvin “Sam” Muszynski, American Psychiatric Association Katie Dzurec, Pennsylvania Insurance Department Please use this as the opening slide of your presentation.

Agenda Overview of MHPAEA QTL and Financial Requirement analysis Subtitle 1 Overview of MHPAEA Timeline Regulatory Provisions Key Terms QTL and Financial Requirement analysis NQTL analysis Resources for Regulators Please use these for slides that will use headers and/or sub headers.

Legislative & Regulatory Timeline Overview of MHPAEA Legislative & Regulatory Timeline Oct 3, 2008 MHPAEA passed, amending PHS Act, ERISA, & IRC Feb 2, 2010 Interim Final Rule published Nov 13, 2013 Final Rule published Jul 1, 2014 Final Rule effective Oct 3, 2009 MHPAEA effective July 1, 2010 IFR effective 2008 2009 2010 2013 2014 2016 Mar 23, 2010 Affordable Care Act Sept 23, 2010 ACA EHB reforms effective Dec 13, 2016: 21st Century Cures Support for Patients and Communities Act: Oct. 24, 2018 Please use these for slides that will use headers and/or sub headers.

Overview of MHPAEA The rules are sequential and interrelated Essentials The rules are sequential and interrelated Identify MH/SUD disorder Identify MH/SUD benefit Identify med/surg benefit Classification of MH/SUD and med/surg benefits Financial requirements & QTL NQTL – medical necessity, information disclosure Vendor coordination Please use these for slides that will use headers and/or sub headers.

Regulatory Provisions Overview of MHPAEA Regulatory Provisions If a Company provides both med/surg benefits and MH/SUD benefits, then the Company must comply with parity requirements may not apply any financial requirement or treatment limitation MH/SUD benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all med/surg benefits in the same classification Please use these for slides that will use headers and/or sub headers.

Overview of MHPAEA Financial Requirements: Key Terms Financial Requirements: Type – deductibles, copayments, coinsurance, or out-of-pocket maximums Level – the dollar amount or number of visits/sessions Treatment limitations – limits on benefits based on scope or duration of treatment (e.g., frequency, number of visits, days of coverage) Quantitative (QTL) – determine whether or to what extent benefits are provided based on accumulated amounts, such as annual or lifetime day or visit limits. Expressed numerically Nonquantitative (NQTL) – limit the scope or duration of benefits for treatment under a plan or coverage (e.g., prior authorization, formulary design, network) Please use these for slides that will use headers and/or sub headers.

Overview of MHPAEA Key Terms MH/SUD Disorder – consistent with generally recognized standards of current medical practice MH/SUD Benefit – services primarily provided in conjunction with treatment for MH/SUD conditions Classifications Subclassifications Inpatient, in-network Inpatient, out-of-network Outpatient, in-network Outpatient, out-of-network Emergency care Prescription drugs Office/all other for outpatient Drug tiering Provider network tiering Please use these for slides that will use headers and/or sub headers.

For each classification… QTL and Financial Requirement Analysis For each classification… substantially all and predominant level are based on ratio of expected claims dollar amounts for the covered service to the amounts for ALL covered services Does the limit apply to substantially all (2/3) of Med/Surg? What is the predominant level (50%)? MH/SUD levels must be equal to or less than the predominant level STOP! Cannot be applied to MH/SUD YES NO Please use these for slides that will use headers and/or sub headers.

Outpatient, In-Network classification Copay - $244,728,384.78/$717,781,326.50 Coinsurance – $0/$717,781,326.50 Deductible – $206,965,525.50/$717,781,326.50 None of the cost-sharing types meets the substantially all requirement, so no financial requirements can be applied to the MH/SUD outpatient, In-Network classification This template is for illustration of larger charts, images, and intricate visuals that require more space.

Outpatient, In-Network, Office sub-classification Classification: OPTIONAL SUBCLASSIFICATION- OUTPATIENT, IN-NETWORK, OFFICE COLUMN 1 COLUMN 2 Service Categories within OUTPATIENT, IN-NETWORK, OFFICE EXPECTED CLAIM DOLLAR AMOUNT COPAY APPLICATION INSTRUCTIONS: List all MEDICAL/SURGICAL service categories within the OUTPATIENT, IN-NETWORK, OFFICE classification below. INSTRUCTIONS: List Claim Expected Allowed Dollar Amounts (Annual) for each service category listed. INSTRUCTIONS: Is a copay applied to this service category? If yes, list the copay Dollar Amount Applied to the Service Category. If no, put a "N" for every Service Category where there is no copay application. ADULT PREVENTIVE/HEALTH SCREENING EXAMINATION $ 19,634,826.65 N PEDIATRIC IMMUNIZATIONS $ 9,103,247.38 PEDIATRIC PREVENTIVE/HEALTH SCREENING EXAMINATION $ 5,694,170.52 PREVENTIVE $ 24,853,595.57 SCREENING GYNECOLOGICAL EXAM $ 523,633.10 PHYSICAL, SPEECH, AND OCCUPATIONAL THERAPY $ 25,816,315.51 30 PODIATRIC CARE $ 3,967,757.05 PROVIDER OFFICE VISIT (FOR ILLNESS OR INJURY) $ 51,277,517.51 20 SPECIALIST OFFICE VISIT, INCLUDING OB-GYN $ 134,989,926.12 40 THERAPEUTIC MANIPULATION $ 14,817,696.12 URGENT CARE FACILITY $ 13,859,172.47 AGGREGATE TOTAL OF MEDICAL AND SURGICAL BENEFITS EXPECTED CLAIM DOLLAR AMOUNT WITHIN OUTPATIENT, IN-NETWORK, OFFICE CLASSIFICATION $304,537,858.00 For every row in COLUMN 2 with an amount listed, ADD the expected claim dollar amounts (COLUMN 1) for the service category listed within that row.   AGGREGATE TOTALS $ 244,728,384.78 DIVIDE the AGGREGATE TOTAL of all rows with COPAY listed (COLUMN 2), indicating copay is applied, by the AGGREGATE TOTAL of COLUMN 1. If the amount listed within this row is not greater than or equal to 2/3, or 66.67%, the QTL cannot be applied for this plan design. 80.36% Outpatient, In-Network, Office sub-classification Copay meets substantially all for TYPE, so we go to predominant level to see what the maximum amount can be… LEVELS OF COPAYS, LOWEST TO HIGHEST TOTAL EXPECTED CLAIM DOLLARS APPLIED AT THIS COPAY LEVEL PERCENT (%) OF CLASSIFICATION APPLIED AT THIS LEVEL [LEVEL $ AMOUNT DIVIDED BY TOTAL A $] START HERE, MOVE DOWNWARD ONE LEVEL UNTIL AGGREGATE TOTAL OF LEVELS REACH OVER 50.01%; STOP. THAT IS THE PREDOMINANT LEVEL, AND THE HIGHEST LEVEL THAT CAN BE APPLIED TO MH/SUD BENEFITS. $20.00 $51,277,518.00 20.95% $30.00 $58,460,941.00 23.89% 44.84% $40.00 $134,989,926.00 55.16% 100.00% TOTAL A: $ 244,728,385.00

NQTL analysis NQTLs applied to MH/SUD must be Comparable to, and Subtitle 1 NQTLs applied to MH/SUD must be Comparable to, and Applied no more stringently Than those applied to med/surg NQTL analysis must be compliant BOTH as written and in operation Mary: Federal examples, comments.

NQTL analysis Walk through provisions Provide examples Subtitle 1 Mary: Federal examples, comments.

MHPAEA Resources for Regulators Subtitle 1 Please use these for slides that will use headers and/or sub headers.