Mental Health Parity: Don t Take No For An Answer
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1 Mental Health Parity: Don t Take No For An Answer Presented by: Laura Reich Disability Rights California
2 What this training will cover I. DRC II. Stigma and Discrimination III. Overview of mental health parity under state and federal laws IV. Enforcement agencies V. Appeals 2
3 About Disability Rights California (DRC)
4 About DRC - California s Protection & Advocacy System - Mission Statement: Advocate, educate, investigate, and litigate to advance and protect the rights of Californians with disabilities.
5 DRC Services General DRC services include: - Intake & Referral - Self-help materials and other publications - Training - Public policy & legislative advocacy - State hospital patients rights advocates
6 DRC Services - Clients rights advocates for clients of regional centers - Legal counsel & advice - Representation of individuals with disabilities in priority areas - Systemic litigation
7 Stigma and Discrimination
8 What is Stigma Webster s dictionary defines stigma as a set of negative and often unfair beliefs that a society or group of people have about something. Types of stigma: 1. Public Stigma 2. Institutional Stigma 3. Self Stigma 8
9 What is Discrimination? Discrimination occurs when people act on stigma in ways that deprive others of their rights and life opportunities. Unjust deprivation of rights and opportunities due to stigma includes - Exclusion or marginalization of people - Denial of equal health / insurance benefit - Less chance of full participation in life 9
10 Overview of Mental Health Parity Laws
11 Why focus on parity? Historical lack of equal coverage -fewer types of services (e.g. no intermediate care) -more restrictions on accessing treatment (e.g. stricter prior approval requirements) -higher costs for treatment (e.g. copays)
12 Parity Means Equality Mental health parity laws: -created in response to unequal coverage and discrimination -require health insurance plans to provide equal coverage for physical and mental health (including substance abuse disorders) Image from
13 Moving Towards Parity 1996: Congress passed 1 st federal parity law 1999: CA passed Mental Health Parity Act 2008: Congress passed Mental Health Parity and Addiction Equity Act (MHPAEA) 2010: Affordable Care Act extended MHPAEA to more health plans
14 CALIFORNIA PARITY LAW
15 CA Mental Health Parity Act Applies to: Groups of people: -adults who have severe mental illnesses -children who have severe emotional disturbances Types of plans: -health plans that are regulated by the state (individual and small group plans; fully insured large group plans)
16 CA Mental Health Parity Act Does not apply to: Types of plans: - self-funded plans (many large employers and unions offer these type of plans) -Medicare -Medi-Cal -Veterans Administration health plans
17 CA Mental Health Parity Act Covered conditions (for adults): -Major depression -Bipolar disorder -Schizophrenia -Schizoaffective disorder -Anorexia -Bulimia -Panic disorder -Obsessive-compulsive disorder -Autism or pervasive developmental disorder
18 CA Mental Health Parity Act Severe emotional disturbances (for children): 1. has one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and 2. Meets the criteria in W&I Code section (a)(2)
19 CA Mental Health Parity Act Coverage mandate: All medically necessary treatment for the listed severe mental illnesses must be covered under the same terms applied to physical illnesses.
20 CA Mental Health Parity Act Coverage must be equal in terms of: -Maximum lifetime benefits -Copayments -Deductibles Coverage includes: -Outpatient services -Inpatient services -Partial hospital services -Prescription drugs* (*if the plan covers any prescription drugs)
21 CA Mental Health Parity Act Recent case law Harlick v. Blue Shield of California, 686 F (2012). Burton v. Blue Shield of California Life & Health Insurance Co., 2012 WL (C.D.Cal.)(2012). Rea v. Blue Shield of California, 2014 WL , Cal.App. 2 Dist., June 10, 2014.
22 FEDERAL PARITY LAW
23 Affordable Care Act (ACA) ACA creates Essential Health Benefits. -There are now 10 categories of required health coverage for Qualified Health Plans -1 of the 10 categories is mental health and substance use disorder services Must comply with federal parity laws
24 MHPAEA MHPAEA=Mental Health Parity and Addiction Equity Act (2008) Applies to: Types of plans: -employer-based plans (with more than 50 members) -Qualified Health Plans - plans offered on the Exchange (i.e. Covered California) and the same plans offered outside of the Exchange -all individual plans
25 Applies to: (con t) MHPAEA -most small group plans (including all plans subject to the California mental health parity law) -Medi-Cal Managed Care Plans -Medi-Cal Alternative Benefit Plans (Affordable Care Act Medi-Cal expansion)
26 MHPAEA Does not apply to: Types of plans: -grandfathered small group plans (plans from before March 23, 2010) -Medicare Part A and B -Veteran s Administration health plans -Tricare
27 MHPAEA If a health plan offers any mental health or substance use benefits, the plan must provide these benefits at parity to medical and surgical benefits. Unlike California law, there is no coverage mandate. However, if another law, such as the California law, mandates coverage, federal parity requirements apply. Six categories of benefits (benefits must be equal in each category for physical and mental health): 1. Inpatient; in-network 4. Outpatient; out-of-network 2. Inpatient; out-of-network 5. Emergency care 3. Outpatient; in-network 6. Prescription drugs
28 MHPAEA Quantitative limits: Limits that have some numerical value 1. Copays 2. Deductibles 3. How often one gets care 4. Number of visits 5. Days of treatment
29 MHPAEA Non-Quantitative limits limitations that are not based on numbers 1. Formulary design 2. Utilization review 3. Step therapy 4. Geographic Proximity 5. Timely access to care
30 Medi-Cal Expansion As part of the ACA, Medi-Cal coverage of SUD and MH benefits were expanded. Starting on January 1, 2014, Medi-Cal beneficiaries will receive expanded SUD services through county alcohol and drug programs, and MH services through managed care plans. 30
31 ENFORCEMENT AND APPEALS
32 Health care service plans v. health insurance - Health care service plans are prepaid health plans, which contract to provide services when needed. HMOs are health care service plans. Regulated by Department of Managed Health Care. - Health insurance is a type of indemnity insurance, which means that reimbursement for health care costs is on a fee for service basis. Regulated by California Department of Insurance, except for Blue Cross and Blue Shield PPOs. (Blue Cross and Blue Shield PPOs are regulated by DMHC.) 32
33 Other enforcement agencies Responsibility of 1. IRS (Internal Revenue Service within Department of Treasury) 2. EBSA (Employee Benefits Security Administration within Department of Labor) 3. CMS (Centers for Medicare and Medicaid Services) 33
34 APPEALS PROCESS
35 Appeals Process Insurance Denial Internal appeal External Review
36 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
37 External Review 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; The plan will not cover an experimental or investigational treatment for a serious medical condition; The plan will not pay for emergency or urgent medical services that you have already received.
38 Appeals Process: Urgent Health Situations Insurance Denial Internal Appeal External Review
39 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
40 External Review Outcomes Calfornia Department of Insurance (CDI) Independent Medical Review (IMR) 2013 Outcomes (Total: 483) 1% Denial Overturned by IMR 40% Denial Partially Overturned by IMR Denial Upheld by IMR 50% Complaint Withdrawn 9% Data compiled from: help/Independent-Medical-Review- Program.cfm
41 Overturn rates for the five most common mental health illnesses CDI (2013) Alcohol / Drug Disorders Autism 7.9% 19.3% 2.9% 8.6% 3.6% 10.0% Denial Upheld by IMR Denial Partially Overturned by IMR Denial Overturned by IMR Bi-polar 2.9% 3.6% 2.1% Depression (Major) 9.3% 8.6% 11.4% The rates are based on the percentage from the grand total, not the individual diagnosis Eating Disorders 4.3% 2.1% 3.6% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% Data compiled from: consumers/101-help/ Independent-Medical-
42 External Review Outcomes Department of Managed Health Care (DMHC) Independent Medical Review (IMR) 2013 Outcomes (Total: 1547) 46% 23% Denial Reversed by Plan before IMR Denial Overturned by IMR Denial Upheld by IMR 31% Data compiled from: FileaComplaint/ IndependentMedicalReviewa ndcomplaintreports.aspx#.v
43 Overturn rates for the most common mental health illnesses DMHC (2013) Alcohol / Drug Disorders 6.6% 6.2% Denial Upheld by IMR Autism 11.0% 22.0% Denial Overturned by IMR Bipolar 5.3% 3.5% Depression - Severe 14.1% 21.6% The rates are based on the percentage from the grand total, not the individual diagnosis Eating Disorder 1.8% 7.9% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% Data compiled from: FileaComplaint/ IndependentMedicalRevie wandcomplaintreports.as
44 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. 44
45 MH/SUD Resources CalMHSA: Disability Rights CA: Toll Free / TTY Each Mind Matters: 45
46 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.
47
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No. What is not included in the out of pocket limit? Even though you pay these expenses, they don t count toward the out-of-pocket limit.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan s summary plan description at www.psbenefitstrust.com or by calling (206) 441-7574,
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca/sisc or by calling 1-855-333-5730. Important
You can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.careconnect.com or by calling 1-855-706-7545. Important
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.summacare.com or by calling 1-800-996-8701. Important
What is the overall deductible? Are there other deductibles for specific services?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/cuhealthplan or by calling 1-800-735-6072.
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.paramounthealthcare.com or by calling 1-800-462-3589.
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.crystalrunhp.com or by calling 1-844-638-6506. Important