1. Mental Health Parity: Becoming Parity Advocates
Presented by:
Disability Rights California
Christopher Ogata

2. Disability Rights California
DRC is a non-profit legal organization that services as California's protection and advocacy system.
DRC works to
Stop discrimination against those living with disabilities,
Increase access to education, transportation, housing, and employment, and
Increase access to government benefits, public and private healthcare, and regional center services.
Intake Line: (800)

3. Mental Health Parity Project
Helps to advocate for the mental health parity rights of those who have private health insurance.
We Provide
Legal Advice
Technical assistance during the appeals process
In some cases, litigation services
Christopher Ogata

4. CalMHSA
The California Mental Health Services Authority (CalMHSA) is an organization of county governments working to improve mental health outcomes for individuals, families and communities. Prevention and Early Intervention Programs implemented by CalMHSA are funded by counties through the voter-approved Mental Health Services Act (Prop 63). Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California’s diverse communities.

5. Objectives
- Define mental health parity - Differentiate between California and Federal mental health parity laws - Identify potential mental health parity issues with your insurance plan - Communicate with your insurance company and the state in order to appeal denied claims for mental health or substance use treatment

6. Parity Means Equality Mental health parity laws:
- Requires health insurance plans to provide equal coverage for physical and mental health (including substance abuse disorders) - Created in response to unequal coverage and discrimination
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7. Stigma and Discrimination
Stigma and discrimination have resulted in disparities between health care for physical and mental health.
- Disparity: the condition of being unequal
- Stigma: attitudes and beliefs that lead people to reject, avoid, or fear those they perceive as being different
- Discrimination: when people act on stigma in ways that deprive other people of rights and opportunities; treating people differently

8. History of Inequality
Historically, insurance companies have not covered physical health and mental health/substance abuse disorder benefits equally:
- fewer types of services
- more restrictions on accessing treatment
- higher costs for treatment

9. 1996
Congress passed 1st federal parity law, the Mental Health Parity Act
1999
California passed the California Mental Health Parity Act (CMHPA)
2008
Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA)
2010
Affordable Care Act extended MHPAEA to more health plans
Moving Towards Parity

10. Federal vs. California Law
Federal Law
California Law
Does not mandate mental health coverage
(However, “mental health and substance use disorder benefits” are one of the 10 “essential health benefits” required by the Affordable Care Act)
Mandates coverage
Open to all mental health conditions covered by your plan
Limited to “severe mental illness” and “serious emotional disturbances”
Requires “parity” for annual and lifetime coverage limits, financial requirements, and treatment limitations within each of six categories of benefits
Requires coverage for ALL medically necessary treatment

11. Types of Insurance Plans
Employer Group Plans
Self-Insured Plans
Small Self-Insured Plans
Large Self-Insured Plans
Fully-Insured Plans
Small Fully-Insured Plans
Large Fully-Insured Plans
Individual Plans
Insurance Exchange Plans

12. Plans Covered under Original MHPAEA
Employer Group Plans
Self-Insured Plans
Small Self-Insured Plans
Large Self-Insured Plans
Fully-Insured Plans
Small Fully-Insured Plans
Large Fully-Insured Plans
Individual Plans
Insurance Exchange Plans
Plans Covered under MHPAEA
Plans NOT Covered under MHPAEA

13. Plans Covered under Expanded MHPAEA
Employer Group Plans
Self-Insured Plans
Small Self-Insured Plans
Large Self-Insured Plans
Fully-Insured Plans
Small Fully-Insured Plans*
Large Fully-Insured Plans
Individual Plans*
Insurance Exchange Plans*
Plans Covered under expanded MHPAEA
Plans NOT Covered under expanded MHPAEA

14. Plans Covered under CMHPA
Employer Group Plans
Self-Insured Plans
Small Self-Insured Plans
Large Self-Insured Plans
Fully-Insured Plans
Small Fully-Insured Plans
Large Fully-Insured Plans
Individual Plans
Insurance Exchange Plans
Plans Covered under CMHPA
Plans NOT Covered under CMHPA

15. Type of Plan
Federal Law
California Law
Small, Self-Insured Employer Group Plans No
Large, Self-Insured Employer Group Plans
Yes
Small, Fully-Insured Employer Group Plans
Yes*
Large, Fully-Insured Employer Group Plans
Individual Plans
Insurance Exchange Plans (Covered California Plans)
* MHPAEA does not apply directly, but the MHPAEA’s requirements are incorporated by reference and therefore apply to the plan.

16. Federal Parity Laws

17. Federal Parity Law
If a health plan offers any mental health or substance use disorder benefits, the plan must
Apply the same Lifetime Coverage Limits and Annual Coverage Limits as physical health benefits.
Ensure that the plan’s Financial Requirements and Treatment Limitations for mental health are “no more restrictive than the predominant financial requirement applied to substantially all physical health benefits.”

18. Types of Insurance Limits
Quantitative Treatment Limits
Non-Quantitative Treatment Limits
Maximum amount your insurance will pay over your life
Deductibles
Copayments
Coinsurance
Out-of-pocket expenses
Maximum amount your insurance will pay in a year
Annual Coverage Limits
Financial Requirements
Treatment Limitations
Lifetime Coverage Limits

19. Types of Treatment Limitations
Quantitative Limits:
Annual and Lifetime Limits
Deductibles
Copayments
Coinsurance
Frequency of visits
Number of visits
Days of treatment
Non-Quantitative Limits:
Formulary design
Utilization reviews
Medical necessity requirements
Step therapy

20. The Mental Health Parity Act of 1996
Maximum amount your insurance will pay in a year
If mental health benefits are offered, benefits must be the same as physical health benefits.
Annual Coverage Limits
Does NOT apply to substance use disorder benefits.
Lifetime Coverage Limits
Maximum amount your insurance will pay over your life
Applies only to large group health plans
(fifty or more employees).

21. MHPAEA of 2008 Annual Coverage Limits Lifetime Coverage Limits
Quantitative Treatment Limits
Non-Quantitiative Treatment Limits
Maximum amount your insurance will pay over your life
Deductibles
Copayments
Coinsurance
Out-of-pocket expenses
Maximum amount your insurance will pay in a year
Annual Coverage Limits
Financial Requirements
Treatment Limitations
Lifetime Coverage Limits
Expands coverage to include substance use disorder treatment

22. Categories of Treatment
Six categories of benefits (benefits must be equal in each category for physical and mental health):
1. Inpatient; in-network
2. Inpatient; out-of-network
3. Outpatient; in-network
4. Outpatient; out-of-network
5. Emergency care
6. Prescription drugs

23. Federal Parity Law Applies to: Does not apply to:
- All individual plans - Insurance Exchange Plans (i.e., Covered California) - Large and Small Fully-Insured Employer plans - Large Self-Insured Employer Plans - Medi-Cal Managed Care Plans - Federal Employee Health Plans
- Grandfathered small Fully-Insured Employer Plans (plans from before March 23, 2010)
- Small Self-Insured Employer Plans
- Medicare Plans
- Veteran’s Administration health plans

24. Q&A
Q. Carol has a self-funded health plan through her employer. Her psychiatrist feels that she needs weekly therapy sessions to treat her depression. After 10 sessions with an in-network provider, Carol got a letter from her insurance that she has reached the cap on therapy sessions for the year. Is this a parity problem?

25. Q&A
A Probably. Limiting the number of visits to a provider is considered a quantitative treatment limitation. The key here is to find out how the health plan’s limitations on outpatient, in- network care for mental health/substance abuse disorders compare with limitations on outpatient, in-network care for medical disorders. Unless there is a 10-session yearly limit on sessions with substantially all medical/surgical providers, this cap on therapy sessions is a violation of federal parity laws.

26. CALIFORNIA PARITY LAW

27. CA Mental Health Parity Act of 1999
All health care service plans must provide coverage for the diagnosis and “medically necessary” treatment for nine specified “severe mental illnesses” of a person of any age, and for the “serious emotional disturbances” of a child. Benefits must be covered under the same terms and conditions as applied to physical illnesses.
Benefits must be equal for:
- Maximum lifetime benefits
- Copayments
- Deductibles
- Other terms and conditions
Benefits must Include:
- Outpatient services
- Inpatient services
- Partial hospital services
- Prescription drugs (if the plan covers any prescription drugs)
- Basic health care services*
* Basic health services include Physician Services, Hospital Inpatient Services, Diagnostic Laboratory Services, and Preventative Health Services

28. CA Mental Health Parity Act
Severe Mental Illnesses include:
- Major depression
- Bipolar disorder
- Schizophrenia
- Schizoaffective disorder
- Anorexia
- Bulimia
- Panic disorder
- Obsessive-compulsive disorder
- Autism or pervasive developmental disorder

29. CA Mental Health Parity Act
Serious Emotional Disturbance
- Children with a “serious emotional disturbance” are also protected by the California Mental Health Parity Act. “Serious emotional disturbance” is defined more broadly than “severe mental illness.”
- Includes any disorder in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance abuse disorder or developmental disorder.
- The emotional disturbance must also meet the criteria in Welfare & Institutions code § (a)(2). This means that the “serious emotional disturbance” must result in a substantial impairment in two or more categories, and inappropriate behavior according to developmental norms.

30. California Parity Law Applies to: Does not apply to: Types of plans:
- Health plans that are regulated by the state (individual and small group plans; “fully-insured” large group plans)
Groups of people:
- Adults who have “severe mental illnesses”
- Children who have “severe emotional disturbances”
- “Self-funded” plans (many large employers and unions offer these type of plans) - Medicare - Medi-Cal - Veterans Administration health plans

31. Q&A
Anthony was diagnosed with Psychosis NOS last year, and his insurance plan (a state-regulated health plan) would not pay for a partial-hospitalization program. This month, Anthony was diagnosed with Schizoaffective Disorder. Anthony still wants to try the partial-hospitalization program, but he’s worried that his plan will not pay for the program.
What should he do?

32. Q&A
Anthony should try asking again for his insurance plan to cover the program. Now that he has been diagnosed with Schizoaffective Disorder, he has additional protections under California’s Mental Health Parity Act. Anthony’s plan is required to provide medically necessary treatment for Schizoaffective Disorder, including partial-hospitalization services.

33. TIPs for Making the most of your Health Plan

34. Know Your Plan Evidence of Coverage (EOC): Where to find your EOC:
Spending minutes reading key parts of your plan’s Evidence of Coverage can save you a lot of time, money and hassle in the future. It’s much easier to figure out your plan’s rules and procedures when you are feeling well.
Evidence of Coverage (EOC):
- a document (usually a large packet) produced by your health plan that provides details about what your plan covers, how to get services covered, how to appeal a denial, and other important procedures
Where to find your EOC:
- you should have received a copy when you first enrolled in your plan
- if your health plan has a member website, you can usually find your EOC online
- you can call your customer service number and ask for a new copy

35. Know Your Plan Questions to answer about your plan:
- What mental health/substance abuse disorder services are covered?
- Are there any services that I need prior authorization to receive?
- Can I get services outside of my plan’s network? What is the procedure? Is there a higher cost (copay or coinsurance)?
- What should I do in an emergency or urgent situation to make sure services are covered?
- How do I file an appeal? What are the timelines?

36. Evidence of Coverage (EOC)
Look for these key words in your EOC’s table of contents, and read the corresponding sections of your EOC:
“Mental health care”; “Behavioral health care”
“Out-of-plan referral”; “Out-of-network services”
“Emergency and urgent care”
“Excluded services”; “Exclusions”
“Prior authorization”
“Grievances and appeals process”

37. If You Get a Denial
Denial notice: a letter that informs you that your insurance will not pay for a service you requested (called a pre-service denial) or your insurance will not pay a bill for services you already received (called a post-service denial).
What to do: Start by calling your customer service number to find out more about the denial. If you cannot solve the problem by phone, you can appeal the denial.

38. Tips for Calling your Insurance Plan STAY S.H.A.R.P.
Share:
- your name and health plan ID number
- the problem
Have on hand:
- your insurance card
- any denial letters
Ask:
- name of the representative and reference number for the call
- next steps and deadlines
Record:
- date and time of the call
- names and reference numbers
- deadlines
Plan:
- when you will next follow up

39. Appeals Process

40. Appeals Process
Insurance Denial
Internal appeal
External Review

41. Urgent Health Situations
Urgent health situations: A situation where waiting for the standard appeals process could seriously jeopardize your life or your ability to regain maximum function.
You have special rights in urgent situations:
- You can request an internal appeal and external review at the same time
- Much faster timeline (a final decision must be reached as quickly as your medical condition requires—maximum of 4 business days)

42. Appeals Process: Urgent Health Situations
Insurance Denial
Internal Appeal
External Review

43. Internal Appeals
- Most health plans have a fairly simple process for submitting an internal appeal. (There is usually a form and/or instructions attached to your denial notice.) - There may be 1 or 2 levels of the internal appeal. - During the internal appeal process, your insurance company will review your claim again.

44. Internal Appeals
Information to include on your written appeal: - name - claim number - insurance ID number - your contact information - your provider’s name - information supporting why the service should be covered

45. External Review
An external review or “Independent Medical Review” (IMR) is when doctors who are not part of your health services plan review your case.
You can apply for an IMR if your health care services plan denies, changes, or delays a service or treatment because the plan:
determines it is not medically necessary;
will not cover an experimental or investigational treatment for a serious medical condition;
will not pay for emergency or urgent medical services that you have already received.

46. External Review Outcomes
*Statistics are taken from DMHC’s website:

47. External Review Outcomes
*Statistics are taken from CDI’s website:

48. Tips for Appeals
- Keep asking and appealing—denials frequently get overturned at every stage of the appeal process - Keep your appeals factual and brief - Meet all deadlines - Keep detailed records - Ask for help from your health providers

49. Where to get help: Disability Rights California:
Toll Free / TTY
Each Mind Matters:

50. Disclaimer
This area of the law is rapidly developing. These provision are not intended to include all federal and state laws, regulations policy directives or other relevant references. Further legal research is required. The intent here is to provide a general overview of these topics.

51. PEI Statewide Project
The PEI Statewide Project is Prop. 63-funded programs aimed at preventing suicides, reducing stigma and discrimination, and improving student mental health.
Phase I of the PEI Statewide Project, from 2011 to 2015, implemented programs through three initiatives: suicide prevention, stigma and discrimination reduction, and student mental health.
- Phase II of the PEI Statewide Project, from 2015 to 2017, continues the three initiative efforts with an added focus around four wellness areas (diverse communities, schools, healthcare, and workplace) to achieve broad activities that reflect a public health/population based approach for advancing community change.

52. PEI Statewide Project The PEI Statewide Project:
Is voter-approved and funded for by counties through the Mental Health Services Act (Prop. 63)
Transforms California’s mental health services approach by uniting California’s diverse communities to embrace mental wellness and delivering the tools individuals need before they reach the crisis point
Provides an up-front investment that will pay off with sustained cost reductions in health, social services, education and criminal justice programs
Is implemented as a coordinated effort by California’s counties for maximum statewide impact and cost effectiveness