1. Tuerk Conference, Baltimore, MD April 20, 2018
The Mental Health Parity and Addiction Equity 10: Achieving Non-Discriminatory Access to Care
Tuerk Conference, Baltimore, MD
April 20, 2018

2. Presentation Highlight Parity Act Standards
Identify Enforcement Barriers
Identify Strategies to Improve Parity Enforcement
Identify Treatment Barriers and Parity “Fixes”
Advocacy Opportunities - Parity at 10 Maryland Campaign

3. Parity Act – Equal Insurance Coverage
Mental Health Parity and Addiction Equity Act (2008) (Parity Act)
End historic health insurance discrimination against individuals with mental health (MH) and substance use disorders (SUD)
10th Anniversary – How to achieve the promise of the law?
Parity at 10 Maryland Campaign

4. Parity Act – Equal Insurance Coverage
Plans that provide MH/SUD benefits must cover them “equally” (at “parity”) with medical/surgical benefits
Equal benefit coverage
Equal access to benefits
Parity Act does not require plans to cover MH/SUD benefits, but many other laws do
Affordable Care Act – Essential Health Benefits
Maryland law mandates benefit coverage for SUD and MH

5. Maryland Mandated Benefits and Parity Mandates
Insurance Coverage
Maryland Mandated MH/SUD Benefits
Federal Parity Law
Individual ✔
Small Group (100 or fewer employees)
✔ ACA Plans – 50 or fewer employees
Large Group (101+ employees)
Public Employer (self-insured)
✔ State/local plans may opt out
Medicaid (MH/SUD carve-out but enrollees receive MCO medical services)
Medicaid Expansion population
Children’s Health Insurance Program (CHIP)
Describe the full scope of benefits under state law and the new standards for prescription drugs to treat OUD

6. Cost Sharing “Equality” Required Deductibles ($5,000/individual)
Co-payments ($30/visit)
Co-insurance (20% reimbursed amount)
Out-of-Pocket Maximums
Cost Sharing
“Equality” Required
Financial Requirements – Parity Act

7. Limits on Length of Care
Number of visits (15 outpatient visits/year)
Days of Coverage (14 days residential treatment)
Frequency of Treatment (2 episodes of care/year)
Limits on Length of Care
“Equality” Required
Quantitative Treatment Limitations

8. Limits on Scope and Access to Care
Covered SUD/MH benefits (excluded benefits)
Medical Necessity Criteria
Prior authorization and continuing care requirements
Step therapy and fail first
Prescription drugs
Network adequacy and provider admission to networks
Provider reimbursement
“Equality” Required

9. Barriers to Substance Use and Mental Health Care
Parity Act Violation?
Limited Network Providers
Benefit Limits & Exclusions
Burdensome Prior Authorization
Barriers to Substance Use and Mental Health Care

10. Parity Act: Non-Discrimination Standard
Out-of-Pocket Costs and Limits on Length of Treatment
Standard
In Practice
No separate or more restrictive financial requirements or quantitative treatment limitations for mental health and substance use disorder benefits than medical/surgical benefits
Separate – must also apply to 2/3 of medical/surgical benefits
More Restrictive – value must apply to 51% or more of the medical/surgical benefits
Most Plans Comply
Mathematical test - easily applied
Compliance review – easy to identify differences and verify through plan data

11. Parity Act Non-Discrimination Standard
Other Plan Features Limiting Access to Treatment
Standard
In Practice
The “rules” for imposing and applying a non-quantitative treatment limitation (NQTL) on the MH or SUD benefit must be comparable to and applied no more stringently than the rules for imposing and applying the NQTL on medical/surgical benefits
Rules as “written”
Rules in “operation”
Plans do not comply
Requires detailed comparative analysis of virtually all “rules” for coverage of and access to SUD and MH benefits and medical benefits
Requires data analysis to show “no more stringent” application

12. Network Access and Reimbursement
31% of MH/SUD office visits out-of-network v. 3% medical visits out-of-network – Maryland 3rd worst in U.S. (2015)
Rate of disparity for out-of-network use of MH/SUD providers for inpatient, outpatient facility and office visits increased over 3 years ( ).
Primary care providers received 27.6% higher reimbursement than MH/SUD providers for same or similar billing codes (2015)
Network Access and Reimbursement
Milliman Report
Addiction and Mental Health v. Physical Health: Disparities in Network Use and Provider Reimbursement Rates in Maryland
Example of what one would do to address as a parity act violaton
Data year period

13. Transparency – Information Plans Must Disclose
Medical Necessity Criteria – both MH/SUD and medical (patient and provider)
Reasons for any denial of coverage or reimbursement (patient)
Parity compliance documents (patient or provider as authorized representative)
Insurer cannot withhold plan documents based on proprietary information

14. Barriers to Parity Act Enforcement

15. Enforcement Obstacles: Regulators
Don’t get plan information needed to evaluate parity compliance before the plan is approved for sale.
Cost-sharing - can usually identify problems
NQTLs – not identified and compliance information not provided
Investigation strategies – time consuming (market conduct surveys have taken months) and delay fixing violations

16. Enforcement Obstacles: Consumers
Don’t receive complete information about benefits, medical necessity and care authorization or Parity Act Rights
Don’t receive plan information when requested
Unable to conduct complex analysis, particularly in a crisis
Individual complaints do not address systemic plan violations

17. Improve Parity Enforcement
Fix benefit and prescription drug gaps and plan features that limit access to SUD/MH services
Parity Act can guide standard development
Legislative and regulatory responses

18. Adopt effective oversight and compliance strategies
Plans must prove parity compliance before allowed to sell plan
Data auditing – Insurance Dept. and Medicaid

19. Fix Benefit and Prescription Drug Gaps
Maryland Initiatives
Commercial Insurance
Comprehensive Benefit Coverage (HB 1127/SB 968) (2017)
Remove Prior Authorization Medications for Opioid Use Disorders (HB 887) (2017)
Network Adequacy Regulations (2017)
Medicaid
Medicaid Parity Compliance (HB 1217/HB 899) (2016)
Regulations – telehealth, programs bill physician services ( )
1115 Waiver – SUD 3.3, 3.5, 3.7
Benefit Coverage – residential treatment, IOP, diagnostic evaluation, opioid treatment services, medication evaluation and management
PA – methadone, buprenorphine and naltrexone
NA regulatons – in effect as of Dec. 31, 2017 – Travel Distance (urban, suburban and rural); wait times – urgent, non-urgent MH/SUD and routine medical

20. Adopt Effective Oversight and Compliance Strategies
Maryland Initiatives
Commercial Insurance
Parity Compliance Report (HB 1010/SB 586) ( failed)
3rd Market Conduct Survey – Carrier Data (due July 2018)
Network Access Report (annual)
Medicaid
Parity Compliance Report (Due Oct. 2, 2017 and pending)
Identify data from the 3rd MCS -

21. Maryland Parity at 10 Campaign
10 States (3 years) – address key barriers to accessing SUD/MH services through robust Parity Act enforcement.
Maryland – 1 of 5 launch states (IL, NJ, NY, OH)
National and local advocates uniting to achieve equity through education and advocacy.
Establish more effective compliance standards – Plans prove parity compliance before sold

22. Key Barriers Commercial Insurance Network Adequacy
Provider Gaps → Unaffordable Out- of-Network Care
Reimbursement, Contracting, Credentialing Requirements
Limited Access to Residential Treatment (authorization standards)
Billing Restrictions for Program Physicians under BHO Contracts
Complaint Process Ineffective and Burdensome
Key Barriers
Commercial Insurance
Others to add to this List?

23. Key Barriers Medicaid Prior Authorization Requirement
Reimbursement Limitations – Multiple Services Single Day
Benefit Exclusions – some SUD Benefits
Rate Structure – SUD Benefits
Key Barriers
Medicaid
Others to add to this list?

24. Parity Enforcement: Challenge Barriers to Care
Identify Barriers Interfering with Delivering of MH/SUD Care in Practice
Report to regulators
Ask for parity analysis and document disclosure – are rules for SUD/MH benefits comparable to rules for Med/Surg benefits (as written and in operation) and are requirements imposed more stringently on SUD/MH benefits
Patient – Benefit Exclusions and Level of Care Denials
File complaint with carrier and submit to regulators
Ask for parity analysis and disclosure of documents
What you can do as an individual – in your practice. 1st – network admission denials; burdensome requirements; reimbursement rates – low and can’t negotiate; contract standards – seem burdensome’ prior authorization requirements – for all services or concurrent review too frequent.

25. Parity Enforcement: Remove Barriers to Care
Education – Providers, Consumers and Policy Makers
Legislative and Regulatory Advocacy
Annual Data Gathering: identify disparities between MH/SUD and med/surg decision-making that could reflect underlying Parity Act violation
Prospective, pre-market demonstration of parity compliance
Streamline reporting of carrier practices and access problems to regulators

26. Achieving the Parity Act’s Promise
Your Suggestions
Join Parity at 10 Education and Advocacy Work

27. Ellen Weber eweber@lac.org 202-544-5478 Ext. 307