Mental Health Parity: Promises and Issues

Transcription

1 : Promises and Issues Gary M. Henschen, MD, LFAPA Chief Medical Officer for Behavioral Health Texas Association of Health Plans

2 Sep. 23, 2008: The Parity Bill Passes the Senate 2

3 Nov. 8, 2013: Final Rule on Parity Issued Issued jointly by the departments of Treasury, Labor and Health and Human Services Implements the Paul Wellstone and Pete Domenici and Addiction Equity Act of 2008 (MHPAEA) Effective for plan years beginning on or after July 1, 2014 Prior public request for comment on the 2010 interim final rule: how to ensure compliance? Parity analysis: not required every year unless change in plan benefit design, cost-sharing structure or utilization 3

4 Scope of Services Six classifications of benefits: Inpatient in and out-of-network Outpatient in and out-of-network Emergency care Prescription drugs Intermediate levels of behavioral healthcare (e.g., residential treatment center, partial hospitalization program [PHP], intensive outpatient [IOP], etc.) must match physical healthcare services: Residential=skilled nursing=inpatient Intensive/Partial Programs=home health services=outpatient 4

5 Non-Quantitative Treatment Limitations What the MHPAEA does: Strikes phrase clinically recognized standard of care that permitted a difference to justify treatment limits for BH and SUD treatment What this means: Non-quantitative treatment limitations (NQTLs) expanded to exclude restrictions on: Geographic location Facility type Provider specialty Other criteria that limit scope or duration of benefits for services Processes and evidentiary standards/strategies must be comparable Maintains comparable and no more stringently standard-plans must reveal how they determine Plans must supply documents used to determine whether a claim is paid within 30 days of request Provider reimbursement rates a form of NQTL 5

6 Other Points in the Final Rule Disclosure and transparency: medical necessity criteria (MNC) guidelines and application of NQTLs Shared enforcement: states have primary authority, whereas the Centers for Medicare & Medicaid Services (CMS) has authority in non-compliant states and the Department of Labor has authority over self-insured plans State law pre-emption: No state preemption if law more stringent Cost exemption for plans and issuers: formula if increase greater than 2 percent Note: No plans have applied Tiered behavioral health networks must match physical health network tiering Individual market: applies to all plans on or after July 1, 2014 including grandfathered and non-grandfathered plans Governmental plans and non-federal may apply for exemption Prescription tiering must follow NQTLs 6

7 March 31, 2016: Final Rule Implementing MHPAEA within Medicaid Managed Care and Children s Health Effective May 31st of this year! States documentation of parity compliance must be publicly posted on state Medicaid web sites beginning Oct. 2, 2017 Applies to Medicaid fee-for-service when physical healthcare provided through managed care Similar to Nov. 8, 2013 commercial Final Rule Applies to all Children s Health Insurance Program services and Medicaid 1115 waivers Includes long-term care services New standard for out-of-network providers Parity analysis is managed care organizations /health plans responsibility 7

8 State Responsibility States have responsibility for parity analysis States must make available documentation of compliance States are the primary oversight entity CMS will issue additional guidance 8

9 Improving Parity Compliance: Magellan s Recommendations to Federal Parity Task Force Magellan Health submitted public comment to the federal Mental Health and Substance Use Disorder Parity Task Force: Standardize model language for documents and create model classification system Provide additional sub-regulatory guidance on documentation, NQTLs, reimbursement recommendations Simplify existing self-assessment tools with specific examples Disseminate health plan, Medicaid agency, and state best practices Greater collaboration between state and federal government and other stakeholders Improved health plan communication regarding compliance to consumers and providers Remove medical management from the list of NQTLs 9

10 Magellan is Actively Supporting Parity Compliance Educated all health plan and Medicaid partners Ongoing review of state enforcement actions Developed dialogue with American Psychiatric Association leadership Developed audit tool with health plan and Medicaid partners Audited internal processes to ensure compliance Continuous surveillance of internal and external parity compliance concerns 10

11 Quality Oversight Under Parity Continue to review cases to meet the triple aim Right person Right service Right time Outpatient cases reviewed according to clinical algorithms Outreach to outlier practitioners by medical directors Psychotherapy outliers When psychiatric referrals are needed Inappropriate medication regimens RIGHT TIME Medication assisted treatment for substance use disorders Transcranial magnetic stimulation (TMS) Psychological testing 11

12 12 Questions?

13 Confidentiality Statement This presentation may include material non-public information about Magellan Health Services, Inc. ( Magellan or the Company ). By receipt of this presentation each recipient acknowledges that it is aware that the United States securities laws prohibit any person or entity in possession of material non-public information about a company or its affiliates from purchasing or selling securities of such company or from the communication of such information to any other person under circumstance in which it is reasonably foreseeable that such person may purchase or sell such securities with the benefit of such information. The information presented in this presentation is confidential and expected to be used for the sole purpose of considering the purchase of Magellan services. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential. The attached material shall not be photocopied, reproduced, distributed to or disclosed to others at any time without the prior written consent of the Company. 13

14 For more information, contact: Gary Henschen Chief Medical Officer, Behavioral Health