LEGAL & POLICY IMPLICATIONS FOR TREATMENT IN 2014 & BEYOND Carol McDaid Capitol Decisions, Inc. February 10, 2014, AXIS Conference 1

Overview of the Presentation 2  Parity & ACA: Legal & Policy Implications for Treatment for 2014 & Beyond  Parity Federal parity implementation: a chronology Opportunities & challenges Why is parity important to treatment providers? Key provisions in MHPAEA Final Rule Tools for providers: MHPAEA implementation & enforcement Implications for providers & facilities  Changing business practices to optimize MHPAEA & ACA  Affordable Care Act Medicaid expansion The Exchanges

Parity & ACA Chronology 3 The Mental Health Parity & Addiction Equity Act (MHPAEA) becomes law; fully effective 1/1/2011 The Affordable Care Act (ACA) becomes law MHPAEA final rule released on 11/8/13; applies only to commercial plans EHB rule requires SUD as 1 of the 10 essential benefits. Parity applied in & out of exchanges to non- grandfathered plans CMS issues guidance applying parity to MMCOs & CHIP unless state plan permits discriminatory limits

Opportunities  Largest expansion of addiction coverage and reimbursement in a generation  Medicalization, not criminalization, of substance use disorders  Stigma and discrimination reduced  Equitable reimbursement and provider networks for providers and specialists 4

Challenges Like building and flying an airplane at the same time 5

Challenges in Detail  26 states expanding Medicaid  Highly politicized environment in state-federal structure  Less than ½ of states fully implementing ACA  Much of the promise of parity & ACA based on state decision-making  Landmark laws historically take decades for full implementation 6

Why is parity important to treatment providers? 7 Coverage ≠ access MHPAEA requires parity in care management; most state parity laws do not Parity provides a rationale for equitable use of MAT for SUD Without parity, behavioral health cost shift from private to public sector continues while federal funding drops due to ACA Rationale for equal levels & types of care in hostile reimbursement environment Strategy: Encourage DOI to do annual MHPAEA compliance audit like Connecticut’sConnecticut’s

MHPAEA Final Rule: Who & When The rule does not apply to Medicaid managed care, CHIP and alternative benefit plans (more guidance is coming) but law does Continues to allow local & state self-funded plans to apply for an exemption from MHPAEA Applies to the individual market (grandfathered & non-grandfathered plans) Effective for plan years on or after 7/1/14 (1/1/15) 8

 Medicare  Traditional fee-for-service Medicaid  FEHBP  TRICARE  VA MHPAEA Does Not Apply To 9

MHPAEA Final Rule: Scope of Services  Big win for intermediate services (IOP, PHP, residential)  Clarified scope of services issue by stating:  6 classification benefits scheme was never intended to exclude intermediate levels of care  MH/SUD services have to be comparable to the range & types of treatments for medical/surgical within each class  Plans must assign intermediate services in the behavioral health area to the same classification as plans or issuers assign intermediate levels for medical/surgical 10

MHPAEA Final Rule: NQTLs  Strikes provision that permitted plans to apply limits if there was a “clinically recognized standard of care that permitted a difference”  NQTLs are expanded to include geographic location, facility type, provider specialty & other criteria (i.e. can’t let patients go out of state for med/surg treatment and not MH/SUD)  Maintains “comparably & no more stringently” standard without defining the term  Confirms provider reimbursement is a form of NQTL 11

MHPAEA Final Rule: Disclosure & Transparency  Requires that criteria for medical necessity determinations be made available to any current or potential enrollee or contracting provider upon request  Requires the reason for a denial be made available upon request  Final rule now requires plans to provide written documentation within 30 days of how their processes, strategies, evidentiary standards & other factors were used to apply an NQTL on both med/surg & MH/SUD 12

MHPAEA Final Rule: Enforcement  Final rule clarifies that, as codified in federal & state law, states have primary enforcement over health insurance issuers  DOL has primary enforcement over self insured ERISA plans  DOL, HHS & CMS will step in if a state cannot or will not enforce the law 13

Implications  Laws are not self-implementing  Coordinated effort between providers, patients & industry to fully implement & enforce groundbreaking laws  Requires well coordinated networks at state & federal level with common messaging  Sharing effective ACA & parity implementation strategies & replicating successes 14 Strategy: Urge providers & consumers to engage in parity education & advocacy

Changing Business Practices to Optimize Parity  Benefit Verification  Patients should sign release permitting treatment center to be their “authorized representative” with health plan for purposes of obtaining plan documents  As authorized rep, seek a complete copy of patient’s health plan – to compare medical & behavioral benefit  Train benefit verification staff on MHPAEA final rule prior to its full implementation date (plan years on or after 7/1/14) 15

MHPAEA Training at All Levels  Benefit verification staff  Training should include: quantitative & non-quantitative treatment limits, scope of services, prohibitions on facility type & geographic limitations  Staff should know & tell self-insured plans employer is liable for MHPAEA violations  Regularly appeal denied claims; templates available at  Clinical Staff  Documentation must conform to medical necessity criteria  Senior staff  Should be trained in basics of MHPAEA; market will not change unless we are informed ambassadors & drive change 16

State & Local Advocacy  State and local advocacy must be better coordinated to drive state and federal enforcement of MHPAEA and ACA  State and national trade associations should have common goals and strategies for parity & ACA implementation and enforcement 17

Resources  Resources available at  URAC parity standards  Massachusetts parity guidance  Connecticut compliance survey  Maryland parity laws  Nebraska parity compliance checklist  Milliman employer & state guide to parity compliance  Toolkit for appealing denied claims 18

Additional Resources  States & public plans CMS Center for Consumer Insurance Information & Oversight (CCIIO) ext  Employer plans DOL Employee Benefits Administration

Affordable Care Act & Parity  On 1/1/14*, ACA expanded MHPAEA & parity applies to:  Benefits provided in new “exchanges”  Benefits provided by non-grandfathered small group & individual plans  Benefits provided to new Medicaid population  These plans will have to offer a MH/SUD benefit *The Administration is allowing canceled plans (that didn’t meet these requirements) to continue to be offered in 2014; adherence will vary by state 20

Controversial ACA Provisions  “If you like your plan, you can keep it”  Medical device tax  2.3% tax on health plans  Individual mandate & fines  Coverage for contraceptives 21

Who is enrolling in the exchanges?  65 percent previously uninsured  More than one-third have not had a check-up for more than two years  Lower income than those currently covered by private insurance  More racially diverse than the those who currently have private insurance  One in four Exchange enrollees speak a language other than English at home  77 percent of people enrolled through Exchanges have a high school diploma or less 22

Source: Department of Health and Human Services, 2013; Sam Baker, “Three Things You Should Know About the Latest Obamacare Numbers,” National Journal, January 13, Showing Signs of Improvement, Federal Exchange Numbers and Total ACA Enrollment Spiked in December Analysis In December, there was a sevenfold increase in federal exchange enrollments In December, there was a threefold increase in state exchanges While state exchanges saw the most success in the opening two-month period, total enrollment in the federal exchange now outpaces total enrollment in state-based exchanges by 25% The rise in enrollment is due in large part to Dec. 24 deadline for Jan. 1 coverage and technical repairs to HealthCare.gov Overall, ACA enrollment in both state and federal exchanges have undergone a fivefold increase; 1,788,739 additional people selected plans in December The cumulative, three-month ACA enrollment total is 2,153,421 people Health Insurance Exchange Enrollment by Month Monthly Total: 106,185 Monthly Total: 258,497 State exchangesFederal exchanges Monthly Total: 1,788,739 Oct Nov Dec

What can you “buy” on the exchanges?  “Qualified Health Plans” (QHPs)  Private insurance plans  Must cover “essential health benefits”  Must offer certain levels of value (“metal levels”)  Must include “essential community providers,” where available, in their networks  Must have provider network sufficient to ensure access to MH/SUD services without “unreasonable delay”  Must comply with ACA insurance reforms 24 Strategy: Get copies of QHP benefit packages & verify packages are ACA & MHPAEA compliant

How MHPAEA Applies to Exchanges  Per recent guidance:guidance  Plans offered in the exchanges will be required to offer a mental health & addiction benefit at parity  “New” individual & small group plans (plans not in existence on 3/23/10) will also have to offer mental health and addiction at parity  ACA data regs require plans to report on quantitative treatment limitationsregs  MHPAEA guidance requires reporting of NQTLs 25 Strategy: Make sure exchange requires QHP reporting of BH financial & other treatment limits 25

Parity & Medicaid Expansion  January 2013 Medicaid parity guidance  Medicaid MCO plans must comply w/parity unless state plan allows discriminatory limits  Benefits for the “newly eligible” Medicaid population must include MH/SUD at parity  Parity final rule does not apply to MMCOs, CHIP & ABPs  PIC asking for new guidance on application of final rule within 6 months or by 7/1/14  CMS guidance available at : Guidance/Federal-Policy-Guidance.html 26 Strategy: Advocate for CMS parity guidance applying final rule by 7/1/14

Questions? Carol McDaid 27

UNDERSTANDING AND IMPLEMENTING NEW LEGAL REQUIREMENTS Anelia Shaheed Med Pro Billing February 10, 2014, AXIS Conference 28

Overview of the Presentation 29  What will the ACA do to my business ?  New Patients, Policies and Coverage?  New Legal Requirements by the State and Federal Govt?  What will the expansion of Medicare/Medicaid do to my business ?  What should I expect from Insurance Companies ?  In Reimbursement  Performance Requirements  Utilization Review and Medical Records  What am I as a provider required to comply with ?

Overview of Insurance 30 Benefits Verifications Utilization Review Billing and Collections

Importance of Understanding Legal and Ethical Business Operations Whether New or Experienced, every provider in every sector of the mental health and substance abuse industry will undergo changes in the upcoming years. It is important that all areas of your business meet your state and federal guidelines for ethical and legal compliance Mental Health and Substance Abuse is moving into the realm of national scrutiny 31

What will the ACA do to my Business?  New Patients and New Policies  ACA policies vary by state, depending on whether they have initiated own state policies or adopted Federal polices  If you take insurance now you can continue taking these policies  These policies have both IN and OUT of network benefits 32

What will the ACA do to my Business?  As of today there is no change in Medicare recognizing Medicare allowables for primary substance abuse diagnosis in a facility setting  Insurance companies have reporting requirements to participate and performance requirements which means those restrictions will be passed along to you.  Increase in number of medical records and third party audits.  This can be a good thing ! 33

What will the ACA do to my Business?  Under ACA, you do not have to be a Medicare or Medicaid provider in your state to perform services for policies that are sold under the exchanges.  Normal state licensing or insurance company requirements will still apply and may be come more stringent  Under ACA, you can continue to accept self-pay and cash payments  However, if you are balance billing or offering scholarship you must legally compliant with the provision of the Act 34

Legal Requirements for Balance Billing  Medicare and Medicaid Patients and Providers  Some states and plans specifically prohibit amount that may be balanced billed by providers if assignment is on file  Notice of Balance Billing and Collections  Any Bill, Statement or Attempt to collect even if by a provider should be compliant with the Fair Debt Collections Act  In- Contracts strictly can prohibit balance billing 35

Legal Requirements for Marketing and Scholarships  Healthcare Enticement and Kickbacks  Scrutiny of ownership interest in business (check with your state)  Federal requirements – must be for services rendered not just referrals  State requirements – specific states have guidelines for Kickbacks  Write Off/ Scholarships 36

What should I be careful of?  Increased scrutiny by Insurance Companies  Increase in no of audits / medical records  Increase in no of individuals covered by gov’t funding which means as a provider requirement to be compliant with Federal/State req.  Decrease in willingness to contract  Decrease in traditional methods of service by insurance companies (HITECH) 37

What will the Expansion of Medicaid Do for MH/SA  Short Answer…. Increase in individuals covered Not be an immediate source or revenue  If you choose to provide service these individuals all Federal and State practices and requirements apply  New carve-outs through private insurance companies (ValueOptions/BCBS) for Medicaid/Medicare 38

What will Insurance Companies Do?  2013 – Delay of large group implementation / Drops of single individual policies  2013 – Majority of commercial insurance companies will treat ACA policies as commercially priced services  Expect the continuation and increase in allowables (are allowables legal ????)  2014 – Implementation of Large Group 39

What will Insurance Companies Do? What will affect Reimbursement Models  Allowables and Usual and Customary… what do these mean legally?  Disclosure requirements.. I can get information on behalf of the patient but how?  Reporting requirements.. Insurance companies can loose their ability to sell policies and must report information to gov’t. 40

What will Insurance Companies Do? What will affect Reimbursement Models  Provider contact with Insurance Companies  Utilization Review is going to be difficult / published criteria and ability to appeal  CARF and JACHO and other new policy restrictions 41

A Business What Do I need to Do? Financially  Valid and Accurate Licensure from State  Clear Financial Documentation for Billing Insurance and Self Pay compliant with federal and state guidelines  Clear authorization to legally act on behalf patients and subscribers  Clear documentation and procedures for handling patient information 42

A Business What Do I need to Do? Clinically  Appropriate Licensure for Clinically staff, scheduling and oversight  A GOOD MEDICAL RECORD (documentation of medical necessity) 43

A Business What Do I need to Do? Administrative / Accounting  Clear and Compliant protocol for statements, balance billing and scholarship (must be Federal and specific to the state you perform services)  Clear protocols for collection efforts  Documented audits and procedures for ensuring insurance billing compliance  Documented procedures for hardship letters  Tracking your receivables ! 44

A Business What Do I need to Do? Administrative / Marketing  Copyright and Trademark protection  If using a third party vendor / clear distinct separation from organization and contractual compliance with state guidelines  If using a employee / clear documentation that employee is not being paid for referral but for employee related services 45

A Business What Do I need to Do? Administrative / CEO Liability  Ensure proper and legal authorities in your state retain ownership interest (Dr. v. Individuals)  Limited Liability ! (LLP, LLC)  Proper Liability Insurance, EPI Insurance, HIPAA and HITECH insurance, PL insurance  Proper administrative safe guards in place for all areas of the business… provided by a good attorney and accountant who KNOWS HEALTHCARE 46

Questions? Med Pro Billing Melissa Zachariasz President Anelia Shaheed, Esq. 47