M E N T A L H E A L T H P A R I T Y A N D A D D I C T I O N E Q U I T Y A C T ( M H P A E A )

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1 H E A L T H W E A L T H C A R E E R M E N T A L H E A L T H P A R I T Y A N D A D D I C T I O N E Q U I T Y A C T ( M H P A E A ) N E W M E X I C O B E H A V I O R A L H E A L T H C O L L A B O R A T I V E JANUARY 12, 2017 Linda Weaver, PhD, JD Consultant

2 B A C K G R O U N D The Mental Health Parity Act of 1996 Prohibited lifetime and annual dollar limits for mental health if aggregate limits not also applied to medical Mental Health Parity and Addiction Equity Act of 2008 Requires full parity for financial requirements and treatment limitations; expands aggregate limits requirements to substance use disorders February 10, 2010: Interim Final Rules for Commercial Plans November 13, 2013: Final Rules for Commercial plans published March 30, 2016: Final Rule for Medicaid/CHIP published with a compliance date of October 2, 2017 MERCER

3 O V E R V I E W In general, MHPAEA prohibits limits on Mental Health (MH) and Substance Use Disorder (SUD) benefits that are more restrictive than those placed on medical benefits. For example: Cannot have a higher copay for a MH office visit than for a medical office visit (Financial Requirement or FR) Cannot have a 30-day limit on inpatient treatment for SUD services if there is a 60-day limit on all inpatient medical treatment (Quantitative Treatment Limit or QTL) Cannot limit eating disorder treatment to $50,000 per year, if there are no dollar limits on medical treatment (Aggregate Dollar Limit) Cannot require prior authorization for intensive outpatient treatment (IOP) if no outpatient medical services require prior authorization (Non-Quantitative Treatment Limit or NQTL) MERCER

4 W H E N D O E S P A R I T Y A P P L Y? Medicaid MCOs Parity requirements apply to all MH/SUD benefits provided to Medicaid MCO enrollees regardless of whether all MH/SUD and M/S benefits are provided by the MCO ABPs The Medicaid MCO requirements apply to ABPs provided through MCOs Parity requirements apply to non-mco ABPs except for the dollar limit rules CHIP All separate CHIP programs must comply with parity regardless of delivery system Separate CHIP programs providing full EPSDT coverage deemed to comply Medicaid FFS Parity requirements do not apply to Medicaid beneficiaries who are not enrolled in an MCO/not receiving ABP benefits (e.g., PIHP, PAHP, PCCM, FFS only) MERCER

5 H O W D O E S P A R I T Y A P P L Y? How does MHPAEA apply to Medicaid/CHIP benefits? MHPAEA applies to MH/SUD benefits for Medicaid MCO enrollees, including long term care benefits If a Medicaid MCO enrollee receives some benefits on a fee-for-service (FFS) basis, MHPAEA applies to the FFS benefits too MHPAEA applies separately to each benefit package (i.e., benefits provided to a specific population, regardless of delivery system) States are encouraged to apply MHPAEA to benefits even when it isn t required by law (e.g., non-abp FFS beneficiaries) MERCER

6 T Y P E S O F L I M I T S Parity is a simple concept, but MHPAEA application is complex FINANCIAL REQUIREMENTS (FR) Payment by beneficiaries for services received that are in addition to payments made by the state, MCO, (PIHP, or PAHP) for those services. This includes copayments and coinsurance. QUANTITATIVE TREATMENT LIMITATIONS (QTL) Limits on the scope or duration of a benefit that are expressed numerically. This includes day or visit limits. AGGREGATE LIFETIME OR ANNUAL DOLLAR LIMITS (A/LDL) Dollar limits on the total amount of a specified benefit over a lifetime or on an annual basis. NON-QUANTITATIVE TREATMENT LIMITS (NQTLs) Prior authorization requirements, service exclusions, network admission requirements (including provider reimbursement rates), formulary design or other factors that limit the scope or duration of MH/SUD benefits. These requirements/limits must pass specific tests to be permissible under MHPAEA MERCER

7 T Y P E S O F P A R I T Y T E S T S FRs Copays, coinsurance, deductibles, out of pocket maximums (does not include aggregate lifetime or annual dollar limits) QTLs Numerical limits on the scope or duration of benefits including limits on number of days, visit limits The Parity Test for FRs and QTLs: Any FR or QTL applied to MH/SUD is no more restrictive than the predominant financial requirement or QTL applied to substantially all medical/surgical benefits MERCER

8 T E S T I N G FRs AND QTLs Substantially all The substantially all test requires a type of FR or QTL (e.g., copayment or visit limit) to apply to at least twothirds (i.e., substantially all) of the expected payments in a year for all M/S benefits in the same classification If the type of FR or QTL passes the substantially all test, then the predominant test is required to determine the permissible level of the FR or QTL Predominant To pass the predominant test, the level (or magnitude) of the type of FR (e.g., $5 copayment) or QTL (e.g., 60 visit limit) must apply to more than one-half (i.e., the predominant amount) of the payments for M/S benefits in the same classification that are subject to that type of FR or QTL MERCER

9 T E S T I N G N Q T L s NQTL Definition NQTLs are limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits. Soft limits, which are benefit limits that allow for an individual to exceed numerical limits based on medical necessity, are also considered NQTLs. Examples from Final Medicaid/CHIP Rule Medical management standards, e.g., medical necessity or appropriateness criteria and processes or experimental/investigational determinations Prescription drug formulary Admission standards for provider networks Standards for accessing out-of-network providers Provider reimbursement rates Restrictions based on location, facility type, or provider specialty Fail-first policies or step therapy protocols Exclusions based on failure to complete a course of treatment MERCER

10 T E S T I N G N Q T L s Under the policies and procedures of the state/mco, as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits in the classification are comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the NQTL to M/S benefits in the classification The NQTL analysis does not require a oneto-one comparison of an MH/SUD service to an M/S service It is not required that the result of applying an NQTL is the same for MH/SUD and M/S benefits to pass the Parity test MERCER

11 T E S T I N G N Q T L s NQTL: MH/SUD M/S Comparability in writing and operation Processes Strategies Evidentiary standards Other factors Stringency in writing and operation Processes Strategies Evidentiary standards Other factors MERCER

12 A C H I E V I N G C O M P L I A N C E If a benefit package does not meet MHPAEA requirements, the state can: Amend the state plan so the package complies with parity requirements Add benefits or adjust limits in the benefit package provided by the capitated entity (and adjust the capitation rate as necessary) without amending the state plan Facilitate resolution of FRs, QTLS, and/or NQTLs and ask/direct benefit administrators to change policies or procedures MERCER

13 D O C U M E N T A T I O N A N D D I S C L O S U R E S Documentation and Information Availability States must submit documentation regarding MHPAEA compliance with an MCO contract/contract amendment for a carve-out program, an ABP SPA or a CHIP SPA States must provide documentation of compliance with MHPAEA to the general public and post this information on the state s Medicaid website by October 2, 2017 Documentation (and the parity analysis) must be updated when there is a change that impacts compliance Certain information (criteria for medical necessity determinations and reasons for payment denials) must be made available upon request MERCER

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