1. for Advocacy Parity: Fairness in Health Coverage
NAMI Smarts
for Advocacy Parity: Fairness in Health Coverage
Module Five NAMI Smarts for Advocacy
Rev June 2017
© NAMI, Inc. 2013

2. Agenda Welcome What is parity? Signs of parity problems
How to complain
Stories: parity problem or not?
Practice filing a complaint
Wrap-up 3

3. Ground Rules Participate fully Help keep us on time
To help everyone get the most out of this training, we ask you to agree to the following:
Participate fully
Help keep us on time
Turn off cell phones 2

4. What is Parity?
Mental health or substance use treatment must be covered by health insurance at the same level as other types of medical care:
Treatment limits
Out of pocket costs
Review for treatment approval 4

5. for most types of health plans
It’s the law of the land
Parity is required
by federal law
for most types of health plans 5

6. Major Parity Laws
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
The Patient Protection and Affordable Care Act of 2010 (ACA)
21st Century Cures Act of 2016 6

7. Mental Health Parity & Addiction Equity Act (MHPAEA)
Large employer sponsored health plans
50+ employees
Includes self-insured
Medicaid managed care plans
Does not require plans to offer mental health or addiction treatment benefits, but…
If covered, then benefits must be at the same level as for other types of medical care. 7

8. Patient Protection & Affordable Care Act (ACA)
Consumer protections
Medicaid eligibility: 138% of poverty
Extends parity to:
All individual and small group health plans
Medicaid expansion alternative benefit plans
Children’s Health Insurance Plans (CHIP)
Insurance Exchanges/Federal Marketplace
10 essential health benefits (EHB)
– Includes MH/SUD benefits
– All EHB categories must meet parity 8

9. WHY is Parity still a Problem?
Writing the rules took years Final MHPAEA rules were issued:
2013 for private insurance
2016 for Medicaid/CHIP
Federal and state oversight is complicated and unclear
Health plans must make profits for stakeholders. They take advantage of loopholes, gray areas and lack of enforcement. 9

10. 21st Century Cures Act Broad research & health service law
Enforces parity:
Guidance on how plans should comply
Meeting to improve federal/state parity enforcement
Annual report on parity complaints
Government Accountability Office (GAO) study
Non-quantifiable treatment limits (NQTL)
How to improve enforcement
Resources on parity for eating disorder treatment 10

11. MOST Health Plans must Meet Parity, Except…
Medicare
Medicaid fee for service
State and local government plans
Faith-based health plans
Retiree only plans
Tricare
Grandfathered plans
Small group (2 – 50 employees)
Individual
Purchased before 2010 & unchanged 11

12. What must be at the same level?
Inpatient care:
In-network
Out-of-network
Outpatient care:
Residential treatment
Emergency care
Prescription drugs
Co-pays
Deductibles
Out-of-pocket cost limits
Providers in local area
Facility type
Provider payment rates
Standards used to approve or deny care* 12

13. Signs that a health plan
may not be
following parity law… 13

14. than for medical or surgical care
Fewer visits
for MH/SUD care
than for medical or surgical care 4

15. residential or intensive
Doesn’t cover
residential or intensive
MH/SUD treatment
but does for other conditions 4

16. than for medical or surgical care
Higher costs
for MH/SUD care
than for medical or surgical care 4

17. as not ‘medically necessary’
MH/SUD care
denied
as not ‘medically necessary’
but health plan does not share
standards used to decide 4

18. Having to ask permission
to get MH/SUD care covered,
more than for other health conditions 4

19. but can for other health care
Can’t find MH/SUD
in-network providers
but can for other health care 4

20. Got a Parity Problem? SPEAK UP! Complaints and appeals help you
get the care you have a right to
under parity law
…and make the law stronger for everyone 4

21. state department of insurance Consumer Complaint Office
Start with your
state department of insurance
Consumer Complaint Office 4

22. How to file a complaint Talk with your MH/SUD provider
Contact the health plan customer service office
Not resolved? File a complaint with your plan
Contact the government*
For information
For help filing a complaint with the health plan
To file a complaint if not satisfied with health plan
* See chart in handout 4

23. Not sure where to complain?
Federal HHS parity complaint website
Information
Links:
Federal agencies
State insurance departments 4

24. Sample Story 1 Listen to a personalized email Listen to a quick email
59-year-old man with an individual health plan purchased through the state health insurance exchange
Listen to a personalized
Listen to a quick
Notice the impact of just a few lines
“My brand name diabetes medication is on tier 1 with no coinsurance, but my mental health medications are on tier 3 and I can’t afford $ out of pocket every month.
I have to ‘step up’ by taking less expensive psych meds for 6 weeks. I only get the one I need if the other doesn’t work. I changed health plans twice before and had to ‘step up’ each time. Why can’t they look at my record and approve the right drug from the start?”
Does this story have parity issues? If so, what?
What is the first step he should take?
What government agency should he contact? 14

25. Sample Story 2 Listen to a personalized email Listen to a quick email
38-year-old married woman, covered by husband’s small group employer-sponsored plan
Listen to a personalized
Listen to a quick
Notice the impact of just a few lines
“My health plan requires prior authorization for mental health, but not for medical care. The doctor prescribed TMS * for my depression, but my health plan denied the service as ‘not medically necessary’ despite the fact that I’ve tried everything.”
Does this story have parity issues? If so, what?
What is the first step she should take?
What government agency should she contact? 14

26. Sample Story 3 Listen to a personalized email Listen to a quick email
20 year old single woman with Medicaid managed care Her mother is speaking:
Listen to a personalized
Listen to a quick
Notice the impact of just a few lines
“Our Managed Care Organization (MCO) evaluated medical necessity for day hospital treatment almost on a daily basis. That made no sense because the decision to admit our daughter to this type of treatment was based on her receiving residential care for four weeks. Care was denied several times while she was there and it was a constant struggle to extend the stay.
I don’t understand why this is different than her stay in the rehab facility after she broke her leg.”
Does this story have parity issues? If so, what?
What is the first step he should take?
What government agency should he contact? 14

27. Practice filing a complaint
Now it’s your turn…
Practice filing a complaint
In pairs:
One person plays the member
The other is the provider
Situation: A request for individual therapy for PTSD has been denied. The health plan requires group therapy first, but the member is nervous around strangers.
Complete the state health insurance complaint form together. 15

28. Congratulations!
What did you learn?
How will you use it? 25

29. Kennedy Forum Complaint Portal
Collects stories for advocacy
We need your voice! 4

30. Consumer Resources State: Federal: Advocacy Organizations:
State Insurance Department
Medicaid Customer Service Office
State Mental Health Authority Consumer Affairs
Federal:
Department of Labor (DOL) EBSA:  
CMS:
SAMHSA:
Advocacy Organizations:
Depression Bipolar Support Alliance (DBSA):
Mental Health America:
NAMI:
ParityTrack: 26

31. Please turn in your evaluation form
We value your feedback
Please turn in your evaluation form 26

32. Authors Angela Kimball, NAMI Sita Diehl, NAMI
National Director of Policy and Advocacy
Sita Diehl, NAMI
Director, State Policy & Advocacy 27
© NAMI, Inc. 2013