1. Mental Health & Addiction Parity:
Getting What is Rightfully Yours
for Mental Health & Substance Abuse Care

2. Agenda Welcome What is parity? Signs of parity problems
Stories: parity problem or not?
How to complain
Practice filing a complaint
Wrap-up
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

3. What is Parity? In health insurance, parity means…
Mental health or substance abuse care must be covered by health insurance at the same level as other types of medical care in terms of:
Treatment limits (like number of visits, hospital days)
Out of pocket costs (like deductibles or copays)
Review for treatment approval

4. Parity is required by federal law 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
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

5. 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
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

6. Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
Large employer sponsored health plans
50+ employees
Includes self-insured
Medicaid managed care plans
Does not require plans to offer mental health (MH) or substance use disorder (SUD) benefits, but…
If a health plan covers MH/SUD, then benefits must be at the same level as for other types of medical care.
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

7. Patient Protection and Affordable Care Act of 2010 (ACA)
Consumer protections
Medicaid based on income to 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
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

8. 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.
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

9. 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
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

10. 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 and unchanged
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

11. 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*
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement
* Health plans must provide medical necessity criteria to their members upon request.

12. Signs that a health plan may not be following parity law…
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

13. than for medical or surgical care
Fewer visits
for MH/SUD care
than for medical or surgical care
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

14. Residential or intensive MH/SUD treatment
The health plan
Residential or intensive MH/SUD treatment
not covered
but covered for other conditions
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

15. than for medical or surgical care
Higher costs
for MH/SUD care
than for medical or surgical care
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

16. as not ‘medically necessary’
MH/SUD care
denied
as not ‘medically necessary’
but health plan does not share
standards used to decide
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

17. Having to ask permission
to get MH/SUD care covered,
more than for other health conditions
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

18. but can for other health care
Can’t find MH/SUD
in-network providers
but can for other health care
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

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

20. Consumer complaint service
Start with your
state department of insurance
Consumer complaint service

21. How to Complain Talk with your MH/SUD provider
Contact your health plan customer service office
Not resolved? File a complaint with your health 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

22. Not sure where to complain?
Federal HHS parity complaint website
Information
Links:
Federal agencies
State insurance departments
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement

23. Sample Mental Health Story
38-year-old married woman, covered by husband’s small group employer-sponsored plan
“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?
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement
* TMS: Transcranial Magnetic Stimulation is used for treatment-resistant depression

24. Sample Addiction Story
A 45-year-old man with an individual health plan purchased through the state health insurance exchange:
Listen to a personalized
Listen to a quick
“I’m trying to recover from a heroin habit that started after my dentist prescribed oxycodone for oral surgery.
My addiction counselor wants me to take Suboxone, but it’s a tier 3 drug in my health plan. I’d have to pay $120 every month. Why am I paying such high premiums if they won’t cover the care I need?”
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. Complaint & Appeal Form
Standard Insurance Consumer Complaint form
Developed by National Association of Insurance Commissioners (NAIC)
Filing a complaint is quick, simple
… and important

26. Kennedy Forum Complaint Portal
Substantially All - applies to 2/3 of benefits within a given classification
Predominant – applies to more than half of type of limit or requirement
Collects stories for advocacy
We need your voice!

27. Consumer Resources Tennessee:
Dept. of Commerce & Insurance:
TennCare Advocacy Program:
Dept. of Mental Health and Substance Abuse Services:
Federal:
Department of Labor (DOL) EBSA:  
CMS:
SAMHSA:
Advocacy Organizations:
NAMI:
ParityTrack:
Community Catalyst:
Depression Bipolar Support Alliance (DBSA):

28. Tennessee Parity Project
Bonnie Hannah Manager of Advocacy & Communications

29. Name Organization name@email.org
Thank you!
Questions?
Name Organization