1. Vice President for Health Initiatives
Addressing the substance use disorder crisis nationally and in the states Strategies to improve enforcement of the mental health parity and addiction equity act
Ellen Weber, JD
Vice President for Health Initiatives
Legal Action Center
January 25, 2019

2. Parity Act Overview
End historic health insurance discrimination against individuals with mental health and substance use disorders. October 2018 – 10th Anniversary.
MH/SUD benefits, if covered, must be covered on the same level as medical/surgical benefits
Most health plans must comply
Large group (51+ employees) – fully insured and self-funded
Exchange plans – individual and small group (50 or fewer employees - fully insured)
Medicaid managed care organizations, Children’s Health Insurance (CHIP), Medicaid Alternative Benefit Plans
Medicare not subject to the Parity Act

3. Parity Act General Standards
Non-discrimination in all plan design features
Out of Pocket Costs (Financial Requirements)
Deductibles, co-payments, co-insurance, out-of-pocket maximums
Numerical limits on treatment (Quantitative Treatment Limitations)
Frequency of treatment, number of visits, days of coverage, days in a waiting period
Limits on Scope and Access to Care (Non-Quantitative Treatment Limitations)
Prescription Drugs
Emergency Care

4. plan design features limiting access to and duration of treatment
Benefit coverage/exclusions Medical management standards – medical necessity or appropriateness criteria Utilization management – prior authorization, concurrent or retrospective review Step Therapy Formulary design for prescription drugs and tiering Network tier design, provider admission standards, including credentialing and contracting standards Provider reimbursement rates and method for determining usual, customary and reasonable charges

5. Parity Act Non-Discrimination Standards
Quantitative Features No separate or more restrictive FR or QTL for mental health and substance use disorder benefits than medical/surgical benefits. Non-Quantitative Features The “rules” for imposing and applying the 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 both as written and in operation.

6. Prescription Drug Benefit Non-Discrimination standards
Single drug formulary with multiple tiers that apply different financial requirements if based on reasonable factors and not whether drug is used for a MH/SUD condition
NQTLs apply to prescription drugs
Drug exclusion Prior Authorization Step Therapy
Tier placement Quantity Limits Other Limitations

7. Why important for Patients and Providers
Benefit and Prescription Drugs
Coverage + Continuum of Care
Utilization management → limiting access to and delaying care
Level of care decisions → limiting access to appropriate care
Patient Access to Care and Affordable Care
Network Adequacy
Reimbursement Rates → higher use of out-of-network services for MH/SUD services and lower reimbursement of MH/SUD providers for same CPT codes (Milliman 2018)

8. Opportunities advocacy & enforcement
Address benefit and prescription drug gaps and health plan design standards that affect access to SUD/MH services
Parity Act can guide standard development
Legislative, regulatory, Attorney General responses
Adopt effective oversight and compliance strategies
Complaint-centric process ineffective and impractical
Pre-market compliance review and data auditing essential
Consumer assistance needed for complaints

9. Legislative initiatives to Address Benefit GaPs and Access Barriers
State Insurance Mandates: Ensuring continuum of care for SUD and MH coverage (hedge against ACA EHB revisions) – Ex: IL, MD, NJ, NY
Limits on Prior Authorization for benefits and/or medications – Ex: DE, IL, MD, NY, NJ.
Network Adequacy Standards: quantitative measures to regulate provider networks for SUD and MH providers
Appointment Wait Times – CA, CO, ME, MD, TX, VT
Geographic Criteria (travel time and/or distance) – CA, CO, DE, MD, MN, MO, NH, NJ, NV, VT, WA

10. initiatives to Address Oversight/Compliance
Annual Compliance Reporting and Review
Regulatory agency initiatives – CA (2014)
Legislative mandate
Private plans - IL and DE (2018)
Medicaid – TN (2018)
Annual Data Reporting and Analysis – CT, MA, TN (Medicaid), VT, NY (biennial beginning 2019)
Ombud Program for Behavioral Health – CO, NY, TX
Medicaid Managed Care Contracting – Parity Act compliance requirements and opportunity for data collection under contracts

11. Going forward
Parity Act addresses key barriers to continuum of SUD/MH services and access to care.
Current enforcement strategies not aligned with law’s framework and ineffective.
Federal Guidance for Enforcement
Department of Labor Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act and Frequently Asked Questions
CMS Parity ComplianceTookit for Medicaid and Children’s Health Insurance Programs

12. Legal Action Center Parity Work
LAC: A Guide to the Federal Parity Law
NY Ombud Program - CHAMP
Addiction Solutions Campaign: Parity Tracking Project: Making Parity A Reality
Compliance Campaign – National and local advocates uniting to enhance enforcement of the Mental Health Parity and Addiction Equity Act.