The Federal Parity Law November 18,

Technical Difficulties? Please Vanessa Severino at or send her a private chat through the webinar platform. 2

Who Is Your Presenter? Karla Lopez, Esq. Staff Attorney Legal Action Center 3

Who Is the Legal Action Center? Non-profit law & policy organization Anti-discrimination & privacy work Substance Use Disorders HIV/AIDS Criminal Records Legal services, litigation, policy, technical assistance 4

Help from Legal Action Center Our website has many resources Call with questions about privacy or discrimination relating to HIV/AIDS, substance use disorders, or criminal records (212) Refer clients See next slide…. 5

Help from Legal Action Center We provide free legal services, including: Assistance with HIV testing & confidentiality Assistance with claims of discrimination based on: HIV status History of substance use disorder Criminal record: Rap sheet review & error correction Certificates of Relief & Good Conduct Job & housing discrimination 6

Today’s Training Explains the federal parity law Tells NYS service providers and advocates how they can take advantage of their rights, and the rights of their clients/patients, under the federal parity law We will take a 5 minute break halfway through today’s webinar 7

Get Credit for your Attendance! HAVE YOU REGISTERED? If you haven’t officially registered with the NYS Department of Health AIDS Institute, please do it now: If you need assistance, contact Vanessa Severino at 8

Today’s Handouts This PowerPoint Letter from NYS DOH re: parity & Medicaid (10/2/2010) NYS Insurance Dept. Circular Letter No. 20 (2009) NYS Dept. of Financial Svc. Insurance Circular Letter No. 5 (2014) NYS Dept. of Financial Svc. Insurance Circular Letter No. 6 (2014) 9 Cont….

Today’s Handouts, cont…. FEHB Program Carrier Letter No Letter from NYS DOH re: overdose prevention program (9/11/2014) Letter from NYS DOH re: PReP (7/24/2014) 2014 Opiate Legislation Package: Bill Summaries 10

Additional Resources LAC Parity Resources: use-resources/parity-health-care-access-resources/ use-resources/parity-health-care-access-resources/ SAMHSA’s parity web page: reform/parity?from=carousel&position=1&date= http://beta.samhsa.gov/health- reform/parity?from=carousel&position=1&date= Parity Implementation Coalition: Coalition for Whole Health: Parity Track: 11

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POLL Have you noticed your patients/clients having more difficulty getting insurance coverage for substance use disorder or mental health treatment than for other kinds of medical and surgical care? Yes No Don’t know/can’t answer 13

POLL How familiar are you with the federal parity law? I’ve never heard of it I’ve heard of it but don’t know much about it I know a lot about it 14

Mental Health Parity & Addiction Equity Act of Overview 2. Who Must Comply 3. What Does It Require 4. The Details 15

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Federal Parity Law: Overview The Paul Wellstone & Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA), often referred to as the “federal parity law,” became federal law in October 2008, after 12 years of advocacy According to Congress, the purpose of the federal parity law is “to counter a history of discrimination and stigma against mental illness and substance- related disorders that has resulted in much less access to care.” 17

Federal Parity Law: Overview The federal parity law requires health insurance plans that cover mental health (MH) & substance use disorder (SUD) benefits to cover them equally (at “parity”) with other medical & surgical benefits 18

Federal Parity Law: Overview This means that it should no longer be more difficult for a patient to have her addiction treatment covered by her health insurance than to have her diabetes treatment covered. 19

Federal Parity Law: Overview Note on State Law: Many states have their own parity laws, including NY Today’s webinar will focus on the federal parity law, which applies to every state in the country NY also passed a package of laws in 2014 in response to the opioid crisis. The laws went into effect in April 2015—see handout. 20

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Federal Parity Law: Who Must Comply First, a few definitions…. Grandfathered plans are those that were in place on March 23, 2010 and have not made certain changes since then Non-grandfathered plans are those that were created after March 23, 2010, or those created before March 23, 2010 that have made certain changes since then Marketplace refers to the health insurance exchanges & marketplaces created by the Affordable Care Act (ACA) 22 Cont.….

Federal Parity Law: Who Must Comply Definitions, cont.…. Self-Insured plans are those where an employer pays directly for its employees' health care claims, rather than purchasing a plan from an insurance company; employers usually hire a third-party insurance company for administrative services such as enrollment and claims processing. Fully-Insured plans are those where an employer purchases a health plan on the commercial market and pays premiums to an insurance company to cover the cost of its employees’ health care claims. 23

Federal Parity Law: Who Must Comply? Most private and public health insurance plans must comply with the federal parity law, including: Large group health plans (i.e., plans offered by private employers with 51+ employees) Medicaid Managed Care plans Medicaid Alternative Benefit Plans (ABPs), including those provided to Medicaid expansion population Children’s Health Insurance Program (CHIP) Individual plans 24 Cont.….

Federal Parity Law: Who Must Comply? Who must comply, cont’d…. Small group plans sold on the New York State of Health marketplace, or sold outside the marketplace and non- grandfathered State & local government employer plans (if self- insured, can opt out) Church-sponsored plans (but can opt out) Federal government employer plans (OPM guidance— see handout) 25

Federal Parity Law: Who Must Comply? But, some health insurance plans do not have to comply with parity, including: Medicare Traditional (fee-for-service) Medicaid Plans that have successfully applied for a cost-increase exemption (don’t know of any in NYS) Grandfathered small group plans offered outside the marketplace (very few exist) Retiree-only plans TriCare 26

Federal Parity Law: Who Must Comply? Note on federal parity law & ACA: The Affordable Care Act (ACA) expanded the reach of the federal parity law by requiring additional types of health insurance plans to comply with parity Not every type of plan listed in the “who must comply” slide was covered by the 2008 parity law; some were added in 2010 by the ACA 27

Federal Parity Law: Who Must Comply? Note on federal parity law & ACA, cont…. The federal parity law does not require health insurance plans to cover MH & SUD benefits; it only imposes requirements on plans that do choose to provide such benefits. However, the Affordable Care Act (ACA) includes MH & SUD benefits in its list of Essential Health Benefits, meaning certain types of plans—namely plans sold to individuals & small groups on the marketplace and Medicaid plans for the “expansion population” under the ACA—must cover those benefits and cover them at parity 28

Federal Parity Law: Who Must Comply? Therefore, some plans must provide MH & SUD benefits to comply with the ACA, and they must provide the MH & SUD benefits equally with medical & surgical benefits because of the federal parity law. 29

Summary: Who Must Comply? If offer MH/SUD, must comply with parity Must offer MH/SUD, and comply with parity Not required to comply with parity** Large group plans Medicaid Managed Care plans Grandfathered individual plans offered outside marketplace/exchange State & local government plans* Church-sponsored plans* Federal govt. plans *May opt out Individual & small group plans sold on marketplace Non-grandfathered small group & individual plans offered outside marketplace Medicaid ABPs Medicare Traditional (fee-for- service) Medicaid Grandfathered small group plans offered outside marketplace Plans w/cost increase exemption Retiree-only Tri-Care **Note: these plans may be required to comply with state parity or other laws 30

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Federal Parity Law: What Does It Require? The federal parity law requires that financial requirements and treatment limitations be no more restrictive for MH/SUD benefits than for medical/surgical benefits. 32

Federal Parity Law: What Does It Require? What are financial requirements and treatment limitations? 33

Federal Parity Law: What Does It Require? What are financial requirements? Deductibles Co-payments Co-insurance Out-of-pocket maximums 34

Federal Parity Law: What Does It Require? What are treatment limitations? There are 2 kinds of treatment limitations: 1. Quantitative Treatment Limitations 2. Non-Quantitative Treatment Limitations (NQTLs) 35 Cont.….

Federal Parity Law: What Does It Require? What are treatment limitations? Quantitative treatment limitations are those expressed numerically, such as Limits on the number of days or visits covered Limits on the frequency of treatment 36 Cont.….

Federal Parity Law: What Does It Require? What are treatment limitations, cont… Non-Quantitative treatment limitations (NQTL) are not expressed numerically, but otherwise limit scope/duration—i.e., medical management tools: Medical necessity criteria Preauthorization requirements Prescription drug formulary design Fail-first or step therapy policies 37 Cont.….

Federal Parity Law: What Does It Require? What are treatment limitations, cont… Non-Quantitative treatment limitations (NQTL), cont.… Standards for provider admission to participate in- network Determination of usual, customary, reasonable amounts Exclusions based on failure to complete a course of treatment Geographic limitations *Note: this is not an exhaustive list 38

CASE STUDY: Question Jay visits a psychologist once per week. His health insurance plan requires a $50 co-payment each time he visits his psychologist. Is this co-payment a financial requirement or treatment limitation that is covered by the federal parity law? 39

CASE STUDY: Possible Answers A. Yes, it is a financial requirement. B. Yes, it is a treatment limitation. C. No, it is not a financial requirement or treatment limitation. 40

CASE STUDY: Correct Answer A. Yes, it is a financial requirement. Co-payments (like the $50 Jay must pay each time he sees his psychologist) are financial requirements, and therefore they must comply with the federal parity law. 41

Federal Parity Law: What Does It Require? Now you know what financial requirements and treatment limitations are… so what does the law say about them specifically? 42

Federal Parity Law: What Does It Require? First, plans may not have separate financial requirements or treatment limitations that apply only to MH/SUD benefits. 43

CASE STUDY: Question Carrie’s health plan imposes a $500 deductible on MH/SUD benefits. The plan does not impose a deductible on medical/surgical benefits. Does this violate the federal parity law? 44

CASE STUDY: Possible Answers A. Yes, it violates the law. B. No, it does not violate the law. 45

CASE STUDY: Correct Answer A. Yes, this violates the federal parity law. Carrie’s plan has a separate financial requirement—the deductible—that applies only to MH/SUD benefits and not to medical surgical benefits. This is not allowed under the federal parity law. 46

Federal Parity Law: What Does It Require? Second, plans must provide out-of-network benefits for MH/SUD services if they provide them for medical/surgical benefits. 47

CASE STUDY: Question Quinn’s health plan allows him to visit both in- network and out-of-network providers for medical/surgical needs (for example, an in-network or out-of-network neurologist). However, his plan only allows him to visit in-network health care providers for MH/SUD treatment (for example, only in-network psychiatrists). Does Quinn’s plan comply with the federal parity law? 48

CASE STUDY: Possible Answers A. Yes, it complies. B. No, it does not comply. 49

CASE STUDY: Correct Answer B. No, this likely does not comply with the federal parity law.* The law says if a plan provides out-of-network benefits for medical/surgical services (like the neurologist), it must provide out-of-network benefits for MH/SUD services (like the psychiatrist). Quinn’s plan is not following this requirement of the law. *It “likely” does not comply, because more information is needed to say for sure. 50

Federal Parity Law: What Does It Require? Third, plans may not apply financial requirements or treatment limitations to MH or SUD benefits that are more restrictive than the predominant financial requirements and treatment limitations applied to substantially all medical/surgical benefits. 51

Federal Parity Law: What Does It Require? What does all that mean? We are going to talk a lot about this one. 52

CASE STUDY: Question Saul’s health plan only allows 30 psychologist visits per year. There is no similar visit limit on the medical/surgical side (for example, he can visit his primary care doctor as often as he wants). Does Saul’s plan comply with the federal parity law? 53

CASE STUDY: Possible Answers A. Yes, it complies. B. No, it does not comply. 54

CASE STUDY: Correct Answer B. No, this likely* does not comply with the federal parity law. Saul’s plan is placing a treatment limitation (visit limits) on MH/SUD benefits (psychology services) that it is not placing on medical/surgical benefits (primary care). Therefore, the plan is applying a treatment limitation to MH/SUD that is likely more restrictive than what it’s applying to medical/surgical. *It “likely” does not comply, because more information is needed to say for sure. This will be discussed in more detail later in the webinar. 55

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Federal Parity Law: The Details Remember, the federal parity law says plans: may not apply financial requirements or treatment limitations to MH or SUD benefits that are more restrictive than the predominant financial requirements and treatment limitations applied to substantially all medical or surgical benefits. What does that mean? 58

Federal Parity Law: The Details How do you know if financial requirements & treatment limitations are more restrictive for MH/SUD benefits than for other medical/surgical benefits? 59

Federal Parity Law: The Details The federal parity law’s regulations require all of a plan’s MH/SUD benefits and all of its medical/surgical benefits to be placed in one of 6 classifications. MH/SUD benefits are compared to medical/surgical benefits within the same classification. 60

Federal Parity Law: The Details 6 classifications: 1. Inpatient, in-network 2. Inpatient, out-of-network 3. Outpatient, in-network 4. Outpatient, out-of-network 5. Emergency care 6. Prescription drugs Note: For Medicaid & CHP, only 4 categories, because no in- network/out-of-network distinction. 61

Federal Parity Law: The Details 6 Classifications, cont.… MH/SUD benefits in a given classification—such as inpatient, in-network—will be compared with other medical/surgical benefits in that same classification to determine whether the financial requirements & treatment limitations on the MH/SUD benefits are more restrictive. In other words, compare like with like. 62

CASE STUDY: Question Jay is wondering whether the $50 co-payment he is required to pay at his weekly visit to his psychologist complies with the parity law—that is, whether this financial requirement for an MH/SUD benefit is equal to similar medical/surgical benefits. Should Jay check to see whether the $50 co-payment for his psychologist visits is equal to: A. The co-payment he makes when he visits his primary care physician, or B. The co-payment he makes for a visit to the emergency room? 63

CASE STUDY: Correct Answer A. The co-payment he makes when he visits his primary care physician Jay first needs to find out how his insurance plan classifies his psychologist visits, but they are most likely in the “outpatient” category. Therefore, Jay would need to compare his co-payment for the psychologist—an outpatient visit—to his co-payment for outpatient visits on the medical/surgical side, such as visits to a primary care physician when he is sick. By contrast, a visit to the emergency room would presumably fall into the “emergency care” category, and therefore its co-payments should not be compared to co- payments in the “outpatient” category. 64

CASE STUDY: Correct Answer, cont. Remember: Compare like with like! 65 MH/SUDMedical/Surgical Inpatient Detoxification Inpatient Appendicitis Outpatient Psychologist visit Outpatient Primary care visit when sick Emergency Care ER for overdose Emergency Care ER for broken leg Prescription Drugs Suboxone Prescription Drugs Blood pressure medication

Federal Parity Law: The Details 6 Classifications, cont.… If a health plan offers MH/SUD benefits in any classification, MH/SUD benefits must be provided in every classification in which medical/surgical benefits are provided. 66

CASE STUDY: Question Gloria’s health insurance plan covers both outpatient and inpatient treatment for medical/surgical ailments. For example, it covers outpatient visits to her primary care doctor when she gets sick, and inpatient stays at the hospital when she has appendicitis. Her plan also covers outpatient MH/SUD treatment— for example, outpatient addiction counseling. However, her plan will not cover inpatient detoxification for her addiction. Does Gloria’s plan meet the requirements of the federal parity law? 67

CASE STUDY: Possible Answers A. Yes, it meets the requirements of the law. B. No, it does not meet the requirements of the law. 68

CASE STUDY: Correct Answer B. No, it probably* does not meet the requirements of the federal parity law (meaning it is probably illegal). Because Gloria’s health plan offers MH/SUD benefits in any classification (in this case, it offers them in the outpatient classification), it must offer them in every classification in which it offers medical/surgical benefits (in this case, both outpatient and inpatient). *It “probably” does not comply, because more information is needed to say for sure. 69

Federal Parity Law: The Details Once all of the benefits have been put into one of the 6 classifications, how do you compare financial requirements & treatment limitations for MH/SUD vs. medical/surgical to figure out if they are more restrictive for MH/SUD? 70

Federal Parity Law: What Does It Require? For FINANCIAL REQUIREMENTS and QUANTITATIVE TREATMENT LIMITATIONS : cannot impose any on MH/SUD benefits that are separate from or more restrictive than the predominant ones applied to substantially all medical/surgical benefits in the same classification 71

Federal Parity Law: The Details What does all that mean? 72

Federal Parity Law: What Does It Require? What do I need to know about “predominant” and “substantially all”? They are part of a mathematical formula created by the law for comparing MH/SUD benefits with medical/surgical benefits. You don’t need to get bogged down in the details of the formula. If you see something that looks like a violation of the parity law, you can report it to the appropriate entity and they will do the analysis using the formula. We’ll talk more about that later. 73

Federal Parity Law: The Details For NON - QUANTITATIVE TREATMENT LIMITATIONS (NQTLs): cannot impose any on MH/SUD that are not comparable to those used for medical/surgical, and cannot apply them more stringently to MH/SUD than medical/surgical 74

CASE STUDY: Question Frannie’s health plan requires her to get prior authorization that a treatment is medically necessary for all inpatient medical/surgical benefits and all inpatient MH/SUD benefits. In practice, her plan routinely approves seven days of inpatient benefits for medical/surgical conditions, after which the patient's attending provider must submit a treatment plan for approval. On the other hand, Frannie’s health plan routinely approves only one day of inpatient MH/SUD benefits, after which her attending provider must submit a treatment plan for approval. Does Frannie’s plan violate the federal parity law? 75

CASE STUDY: Possible Answers A. Yes, it violates the law. B. No, it does not violate the law. 76

CASE STUDY: Correct Answer A. Yes, it violates the law. Frannie’s plan is applying a stricter non-quantitative treatment limitation in practice to MH/SUD benefits than is applied to medical/surgical benefits. Even if a NQTL is equal on paper, if it is applied more stringently in practice it can still violate the law. 77

CASE STUDY: Question Otto’s health plan applies concurrent review to types of inpatient care where the length of stay tends to vary greatly. The plan uses a mathematical formula to determine which types of inpatient care have a lot of variation. In practice, after applying the formula, the plan applies concurrent review to 60 percent of MH/SUD conditions, but only 30 percent of medical/surgical conditions, because the formula found more variation in MH/SUD inpatient stays than in medical/surgical. Does Otto’s plan violate the federal parity law? 78

CASE STUDY: Possible Answers A. Yes, it violates the law. B. No, it does not violate the law. 79

CASE STUDY: Correct Answer B. No, it does not violate the law. Otto’s health plan complies with the federal parity law because the evidentiary standard used by the plan is applied no more stringently for MH/SUD benefits than for medical/surgical benefits, even though it results in an overall difference in the application of concurrent review for mental health conditions or substance use disorders than for medical/surgical conditions. 80

CASE STUDY: Question Luke’s health plan automatically excludes coverage for inpatient SUD treatment in any setting outside of a hospital (such as a freestanding or residential treatment center). For inpatient treatment outside of a hospital for other conditions (including freestanding or residential treatment centers prescribed for mental health conditions, as well as for medical/surgical conditions), the plan will provide coverage if the prescribing physician obtains authorization from the plan that the inpatient treatment is medically appropriate for the individual, based on clinically appropriate standards of care. Does Luke’s plan violate the federal parity law? 81

CASE STUDY: Possible Answers A. Yes, it violates the law. B. No, it does not violate the law. 82

CASE STUDY: Correct Answer A. Yes, it violates the law. Although the same non-quantitative treatment limitation—medical appropriateness—is applied to both MH/SUD benefits and medical/surgical benefits, the plan's unconditional exclusion of SUD treatment in any setting outside of a hospital is not comparable to the conditional exclusion of inpatient treatment outside of a hospital for other conditions. 83

Federal Parity Law: The Details This stuff is confusing…if the details get overwhelming, just look for the RED FLAGS! 84

Federal Parity Law: The Details Red Flags: Having 1 deductible for MH/SUD services and 1 for medical/surgical services that accumulate separately Limits on the # of days or visits for MH/SUD treatment, when there aren’t similar limits for medical/surgical Higher co-payments & co-insurance for MH/SUD than for medical/surgical (e.g., charging a “specialist” rate for MH/SUD outpatient visits, when a “specialist” rate isn’t charged for most medical/surgical outpatient visits) 85 Cont.….

Federal Parity Law: The Details Red Flags, cont.…. Requiring patient to “fail first” at MH/SUD outpatient treatment before approving residential or inpatient treatment (and not having similar policies for med/surgical) Requiring MH/SUD patients to get prior authorization at earlier stages of treatment or more frequently during treatment than medical/surgical patients 86 Cont….

Federal Parity Law: The Details Red Flags, cont.… Excluding intermediate levels of MH/SUD care, like residential treatment, from coverage, if the plan covers intermediate care (like skilled nursing) for medical/surgical Requiring MH/SUD patients to be treated in-state, but allowing medical/surgical patients to be treated out- of-state 87 Cont….

Federal Parity Law: The Details Red Flags, cont.… Putting yearly or lifetime limit on length of time patient can receive methadone, buprenorphine, or naltrexone—or not covering those medications at all Refusing to cover MH/SUD treatment because patient failed to complete previous treatment or because “the patient is not improving” Refusal to provide information, like medical necessity criteria, when you request it (more on this coming up!) 88

Federal Parity Law: The Details If you see a red flag and don’t want to get bogged down in the complexities of the federal parity law, just report it! Next up: What to do if you see a red flag or think a plan may be violating the federal parity law….. 89

1. Transparency Requirements 2. Appeals 3. Government Enforcement 4. Lawsuit 90

Federal Parity Law: Enforcing Rights Steps to Take: 1. Request information from health insurance plan. 2. File internal appeal; if denied, file external appeal. 3. If appeal(s) denied, contact government agencies that enforce the law. 4. Additional option: Lawsuit. Note: You are not necessarily required to file appeals before contacting government agencies, but they will likely tell you to do so when you contact them before they will get involved. 91

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Enforcing Federal Parity Law: First, Request Information Transparency Requirements: Providers & patients have the right to certain information from health plans under the federal parity law…. 93 Cont.….

Enforcing Federal Parity Law: First, Request Information Transparency Requirements, cont.…. Most plans covered by the federal parity law must provide, if you request it: Criteria used to make medical necessity decisions—both MH/SUD and medical/surgical Written explanation of how non-quantitative treatment limitations (e.g., medical necessity criteria) are applied to their medical/surgical & MH/SUD benefits; Reason for denials of payment or reimbursement; Any additional evidence used to make benefit determinations during appeals. 94

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Enforcing Federal Parity Law: Second, File Appeals Internal & External Appeals: Ask the health plan how to file appeals. Look into expedited appeals if need be. Internal appeals: conducted by the health plan External appeals: conducted by 3 rd party reviewers (not the plan). In NYS most external appeals are conducted by the State Dept. of Financial Services. For both internal & external appeals: Pay careful attention to deadlines! 96 Cont.….

Enforcing Federal Parity Law: Second, File Appeals Internal & External Appeals, cont.…. Community Health Advocates can help with appeals: Tip: Be sure to specifically mention state and federal parity laws in your appeals—otherwise, those laws may not be considered, and courts may not be able to consider them later on if you want them review the outcome of your appeals. 97

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Enforcing Federal Parity Law: Third, Contact Govt. Agencies If you think a health plan is violating the federal parity law, you can complain to the government agencies that are tasked with enforcing the law, or you can complain to the State Attorney General. 99 Cont.….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies New York State Attorney General: NYS AG is proactively enforcing the federal parity law If you think a NYS health plan is violating parity, you can call the AG’s Health Care Bureau hotline: 100 Cont.…

Enforcing Federal Parity Law: Third, Contact Govt. Agencies NYS Attorney General, cont.….. AG has settled 5 cases against NYS health plans for parity violations so far (Cigna, MVP Health Care, Empire Health, ValueOptions/BeaconHealthOptions, & Excellus) For information about what the AG said violated the parity law, as well as copies of the AG’s settlement agreements, visit: health-care-access-resources/new-york-attorney-general- parity-enforcement/ 101

Enforcing Federal Parity Law: Third, Contact Govt. Agencies New York State Attorney General, cont.… The AG can also enforce other federal laws (like the ACA) and state laws (like the state parity law). 102

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Other Govt. Enforcement Options: The AG is just one option for enforcing the parity law The federal parity law itself gives enforcement authority to a variety of state and federal agencies Different agencies enforce federal parity law for different types of health plans Remember, it is advisable to appeal directly to the insurance plan before going to a government agency 103 Cont.….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Medicaid Managed Care & CHP: For suspected parity violations… Primary enforcement responsibility: State Medicaid Director. You can complain to: NY Dept. of Health— Cont.….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Medicaid Managed Care & CHP, cont.… If a State Medicaid Director is not “substantially enforcing” federal parity, you can complain instead to the U.S. Dept. of Health & Human Services about potential parity violations by Medicaid managed care plans: U.S. Dept. of Health & Human Services (877)

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Individual & Small Group Plans: For suspected parity violations…. Primary enforcement responsibility: State Insurance Commissioner You can complain to: NY Dept. of Financial Services Online complaint: Cont.….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Individual & Small Group Plans, cont… If a State Insurance Commissioner is not “substantially enforcing” federal parity, you can complain to the U.S. Dept. of Health & Human Services instead about potential parity violations by individual & small group plans: U.S. Dept. of Health & Human Services (877)

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Large Group Plans: For suspected parity violations by large group plans, enforcement authority is shared between several agencies, depending on whether the plan is self- insured or fully-insured. If you don’t know whether the plan is self- or fully- insured, you can call the plan and ask, or you can just go ahead and complain about the potential violation to one of the enforcement agencies (after your appeals), who will coordinate amongst themselves to determine who has authority. 108 Cont.….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Large Group Plans, cont.… For suspected parity violations by large group plans: Remember: If you are unsure who to complain to, just pick an agency and they should coordinate amongst themselves 109 Self-Insured Large Group Plans Fully-Insured Large Group Plans U.S. Department of Labor (866) U.S. Department of Treasury (202) State Insurance Commissioner (see previous slide) U.S. Department of Health & Human Services (see previous slide)

Enforcing Federal Parity Law: Third, Contact Govt. Agencies State & Local Government Plans : Depends on whether self- or fully-insured… 110 Self-insured state & local govt. plans Fully-insured state & local govt. plans U.S. Department of Labor (866) State Insurance Commissioner (see previous slide) U.S. Department of Treasury (202) U.S. Department of Health & Human Services (see previous slide)

Enforcing Federal Parity Law: Third, Contact Govt. Agencies That’s a lot of information! Don’t worry too much about which government agency has enforcement authority over which type of plan; the federal government agencies have said they will help patients’ & providers’ complaints get to the appropriate agency. 111

Enforcing Federal Parity Law: Third, Contact Govt. Agencies A few tips for complaining to govt. agencies: Mention the federal parity law specifically in your complaint—otherwise the agency may not look for parity violations Ask the government agency to provide you with its findings/conclusions in writing 112

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Enforcing Federal Parity Law: Additional Option—Lawsuit Depending on what type of health plan she has, a patient may be able to enforce her rights under the federal parity law by filing a lawsuit in court against the insurance company To pursue this option, you and/or your patient should speak to an attorney New York State Psychiatric Association v. United Healthcare 114

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Other Laws to Know Court-Ordered Treatment—Insurance Coverage: NYS law requires Medicaid Managed Care plans in the state to cover court-ordered treatment (if the plan would otherwise cover that type of treatment) Example: Court orders defendant charged with sale of controlled substances into outpatient addiction treatment. If the person’s Medicaid plan provides coverage for outpatient addiction treatment generally, it would be required to cover that type of treatment when ordered by a court. This law is found at New York Social Services Law section 364-j(4)(r) 116

Other Laws to Know In June 2014, Gov. Cuomo signed a package of bills into law to combat NY’s opioid epidemic. The new laws require: All insurance policies that are regulated by the NYS Dept. of Financial Services and that provide hospital, major medical, or other similar comprehensive coverage must provide inpatient and outpatient services for the diagnosis & treatment of SUD, including detoxification & rehabilitation services. Financial requirements & treatment limitations of such coverage cannot be more restrictive than medical/surgical, and the coverage must comply with the federal parity law. 117 Cont.….

Other Laws to Know New NY Laws to Combat Opioid Epidemic, cont… When NY insurers undertake utilization review for SUD treatment, they must employ “recognized evidence-based & peer reviewed clinical review criteria.” NY insurers must complete utilization review within 24 hours of receiving a request for inpatient SUD treatment, as long as the request is made 24 hours prior to discharge from inpatient; cannot deny coverage while UR is pending on basis of medical necessity or lack of prior authorization. 118 Cont.….

Other Laws to Know New NY Laws to Combat Opioid Epidemic, cont… NY insurers must issue a decision within 24 hours of receiving an appeal of a denial of inpatient SUD treatment; if appeal is filed within 24 hours of the denial, insurer cannot deny treatment on the basis of medical necessity or lack of prior authorization while the appeal is pending. 119

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