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Mental Health Parity & Addiction EquityCommunity Forum

Katharine Ligon, M.S.W.Policy Analyst, Center for Public Policy Priorities

Rachel Bowden, MPAff, PMPProgram Specialist VI, Texas Department of Insurance

Presenters

Agenda• History and Context Prior to Federal Parity Law

• Overview of Federal Parity Law

• Overview of Texas Parity Law

• Parity Law and the Affordable Care Act

• Parity Advocacy Next Steps

• Texas Department of Insurance Scope of Regulatory Authority and Regulatory Approach

• Q&A

Profile: Mental Health and Substance Use in Texas

Adults

17 million working-age adults (ages 18 to 64 years) in Texas 3.7 million some type of mental disorder

848,000 adults had a Serious Mental Illness

441,000 adults had a Serious and Persistent Mental Illness

1.7 million adults had a chemical dependency

Children and Adolescents

3.2 million Texas children between ages 9 to 17 years in 2012:

634,000 children/adolescents had some type of diagnosable mental disorder.

159,000 children/adolescents had a Serious Emotional Disturbance

Texas DSHS estimated that in 2010 more than 174,000 Texas adolescents (ages 12 to 17) had a chemical dependency.

Prior to Mental Health Parity and the Affordable Care ActBarriers for Individuals with Mental Illness and/or Substance Use Disorders

• Discriminatory benefits for MH/SU

• Denial of health insurance for pre-existing conditions

• Annual caps of dollar amount for health care

• Lifetime dollar amount limits on health insurance benefits

• Higher premiums for illness

• Limited coverage for certain illness

Timeline of Mental Health Parityin the United States

1960s 1970s 1980s1950s 1990s

Deinstitutionalization begins, creating a modest incentive for private insurers to cover services not paid for by the public sector.

Deinstitutionalization begins, creating a modest incentive for private insurers to cover services not paid for by the public sector.

The Federal Employees Health Benefits Program allows participating plans to reduce their mental health benefits.

The Federal Employees Health Benefits Program allows participating plans to reduce their mental health benefits.

Healthcare costs increased dramatically and mental health coverage was dropped or reduced by many employers to try to reduce healthcare insurance costs.

Healthcare costs increased dramatically and mental health coverage was dropped or reduced by many employers to try to reduce healthcare insurance costs.

President Kennedy urged the Federal Employees Health Benefits Program to cover psychiatric illnesses comparably to medical conditions.

President Kennedy urged the Federal Employees Health Benefits Program to cover psychiatric illnesses comparably to medical conditions.

Senators Domenici and Wellstone elevated mental health parity on the public agenda; consumer advocates characterized lack of parity as discrimination.

Senators Domenici and Wellstone elevated mental health parity on the public agenda; consumer advocates characterized lack of parity as discrimination.

Sources: Barry, C. L., Huskamp, H. A., & Goldham, H. H. (2010). A political history of federal mental health and addiction insurance parity. The Milbank Quarterly: A Multidisciplinary of Population Health and Health Policy, 88(3), 404-433. Quass, L. (2012). Federal efforts to achieve mental health parity: A step in the right direction, but discrimination remains. Legislation and Policy Brief, 4(1). 35-72.

Federal Mental Health Parity Mental Health Parity Act of 1996

•Equated aggregate lifetime limits and annual limits for mental health benefits with limits for medical/surgical benefits

•Applied to group health plans and health insurance issuers

•No mandate for MH/SU benefits

•Did not apply to coverage for substance use or chemical dependency

Timeline of Mental Health Parityin the United States (cont‘d)

1999 2002 20031996 2008

Mental Health Parity Act (MHPA) passesMental Health Parity Act (MHPA) passes

President Bush stated support for mental health parity

President Bush stated support for mental health parity

The New Freedom Commission on Mental Health’s final report recommended mental health parity

The New Freedom Commission on Mental Health’s final report recommended mental health parity

At the first White House Conference on Mental Health, President Clinton announced mental health and substance use parity in Federal Employees Health Benefits Plan

At the first White House Conference on Mental Health, President Clinton announced mental health and substance use parity in Federal Employees Health Benefits Plan

Mental Health Parity and Addiction Equity Act (MHPAEA) passes

Mental Health Parity and Addiction Equity Act (MHPAEA) passes

Sources:

Barry, C. L., Huskamp, H. A., & Goldham, H. H. (2010). A political history of federal mental health and addiction insurance parity. The Milbank Quarterly: A Multidisciplinary of Population Health and Health Policy, 88(3), 404-433.

Quass, L. (2012). Federal efforts to achieve mental health parity: A step in the right direction, but discrimination remains. Legislation and Policy Brief, 4(1). 35-72.

Federal Mental Health Parity Wellstone-Domenici Mental Health Parity and Addiction

Equity Act of 2008 (MHPAEA)•Federal oversight MH Parity:

• Department of Treasury

• Department of Labor

• Department of Health and Human Services

•Timeline of Rules:

• 2009 - Proposed Rules with request for public comments

• February 2010 – Interim Final Rules released

• April 2010 – majority of Interim Rules became effective (as if law)

• November 2013 – Rules finalized

• July 2014 – Rules effective

• TBD – Rules for Medicaid managed-care plans

Federal Mental Health Parity MHPAEA: Implementation •Requires the coverage terms for MH/SU benefits be no more restrictive than the coverage terms for medical/surgical services

• Financial requirements: copays, coinsurance, deductibles

• Treatment limitations: # of outpatient visits, # of inpatient days

•Eliminates annual and lifetime dollar limits for MH/SU benefits

•Allows comparison of MH/SU and medical “intermediate levels of care” (e.g. RTC or intensive outpatient treatment)

•Health plan transparency and greater access to information

Federal Mental Health Parity MHPAEA: Implementation •Employer-based plans with 50+ full-time employees

• Small employers that offer MH/SU coverage do not have to meet parity *Except plans purchased through the ACA Marketplace

•Applies to group health plans and health insurance issuers that choose to offer MH/SU coverage

•Does not require plans to provide MH/SU benefits and coverage of specific diagnoses

•Applies to Medicaid and CHIP managed-care plans

•Does not apply to Medicare; is not required to comply with federal parity to any extent

Federal Mental Health Parity MHPAEA: Implementation

Classification of Benefits:

Cumulative Financial Requirements: deductibles and out-of-pocket limits must combine both medical and MH/SU benefits

Quantitative Treatment Limits: # outpatient visits

Non-Quantitative Treatment Limits (NQTLs): pre-authorization of services, utilization reviews, Rx drug formulary design, fail-first policies

• Inpatient / In-network • Inpatient / Out-of-network

• Outpatient / In-network • Outpatient / Out-of-network

• Emergency Care • Prescription Drugs

Texas Mental Health Parity Texas Department of Insurance Parity Rules

•In 2011, TDI adopted final rules related to MHPAEA of 2008: Financial and treatment limitations can be no more restrictive for MH/SU benefits than for medical benefits

•Do not address Federal Parity Rules (i.e. non-quantitative treatment limits)

•Maintains that large employers do not have to provide MH/SU benefits, except SMI coverage under the Texas Insurance Code

•Maintains that issuers must offer small employers SMI benefits

Texas Substance Use ParityTexas Department of Insurance Parity Rules•Mandates coverage for the necessary care and treatment of chemical dependency for employers of over 250 employees

•Coverage may not be less favorable than that provided for physical illness

•Coverage shall be subject to the same durational limits, dollar limits, deductibles and coinsurance factors that apply to coverage provided of physical illness

•Required coverage is limited to a lifetime maximum of three separate treatment series for each covered individual

•Requires standards be set up for use by insurers, other third-party reimbursement sources and chemical dependency treatment centers

Texas Mental Health BenefitsCoverage for Serious Mental Illnesses (SMI) and Other Disorders

•Large employer groups must provide SMI coverage

•Health insurance issuer must offer small employer groups SMI coverage

•Serious Mental Illness coverage• Quantitative treatments – at least 45 inpatient days & 60 outpatient

visits

• Prohibits lifetime limits on the # inpatient days or # outpatient visits

• Requires financial limitations be same for medical care

ACA Extends MH Parity

ACA Extends MH Parity

Plans must provide MH/SU benefits equal to medical benefits including higher out-of-pocket cost, preauthorization of services, utilization reviews, or a narrower application of “medical necessity”

Texas Parity EnforcementOversight and Compliance

•States do not need to enact separate legislation to enforce federal parity

•Some states have refused to adhere to MHPAEA without adopting state statute

• The Federal departments are working with states to follow federal law

•TDI does approve all group plans prior to being offered by Health Insurance Issuers

•TDI is responsive versus proactive

Texas Parity AdvocacyCategories of Advocacy

•Regulatory

•Consumer

•Provider

•Legislative

Texas Parity AdvocacyRegulatory Next Steps

•Ensuring oversight and compliance through the Texas Department of Insurance (TDI) and Health and Human Services Commission (HHSC)

•Request updated TX parity rules to address Federal Interim and Final Rules and ACA rules

•Work with TDI to ensure consumer complaint process is effective and complaints are being resolved appropriately

Texas Parity AdvocacyConsumer Education Next Steps•Work through the DSHS Council for Advising and Planning (CAP) for the Prevention and Treatment of Mental and Substance Use Disorders

•Make Texas-specific parity information widely available to health insurance consumers

Texas Mental Health Parity Toolkit• What is parity?

• How do I know if my plan meets parity?

• How do I complete the complaint process if I think my plan is not in compliance with parity?

Texas Department of InsuranceHow does the Texas Department of Insurance support parity in insurance coverage of mental health and substance use disorder services?

•TDI scope of regulatory authority

• Limited to fully insured private coverage

•TDI regulatory approach

• Form review

• Network adequacy

• Complaints

TDI’s Regulatory ScopeTDI’s authority is limited:

• In scope: “fully insured” individual and employer health insurance plans and HMOs

• Out of scope: “self-funded” employer plans (employer bears risk) are regulated by the Department of Labor and ERISA

• Medicaid/CHIP: TDI regulates network adequacy for participating managed care organizations

• Medicare: TDI regulates Medicare Supplement plans

Texans by Coverage Type

TDI-Regulated MarketTDI only regulates fully insured individual and employer coverage

Does TDI Regulate a Plan?

If “TDI” or “DOI” is on the insurance card:

YES

MissionTDI’s mission is to protect insurance consumers by:

• regulating the insurance industry fairly and diligently

• promoting a stable and competitive market

• providing information that makes a difference

ApproachTo regulate health insurance, TDI:

• reviews and approves policies before they are sold

• reviews HMO, PPO, and EPO networks

• investigates complaints

• initiates market conduct exams when warranted

Form Review• TDI reviews policy forms for compliance with Texas

requirements

• Checklists: www.tdi.texas.gov/forms/form10accident.html

• Texas requirements for group health plans

• Chemical dependency mandated benefit (TIC Ch. 1368)

• Serious mental illness mandate for large group plans, mandated offer for small group plans (TIC Ch. 1355, Subchapter A)

• Parity for mental health and substance use disorder benefits in large group plans (28 TAC Chapter 21, Subchapter P)

Form Review

Federal Review • Federal regulators review individual and small group

health plans for ACA requirements:

– Required categories of essential health benefits include mental health and substance use disorder services

– EHB rules require provision of MH/SUD services to comply with parity

• EHB benchmark plan complies with Texas’ chemical dependency mandated benefit and includes serious mental illness coverage

– Federal EHB extends Texas requirements to individual market

Understanding Coverage• TexasHealthOptions.com provides a guide to help

consumers understand insurance documents, cost-sharing, networks, and balance billing

• TDI has resources to explain which benefits should be covered by all plans:

• Mandated benefits chart:• www.tdi.texas.gov/hmo/documents/manhealthben.pdf

• EHB benchmark plan summary chart: • www.texashealthoptions.com/cp2/healthcare.html

Policy DocumentsYour insurance policy is the primary source for understanding what is covered and how it’s covered (cost sharing, prior authorization, etc.)

• Summary of Benefits and Coverage provides a standardized plan summary for comparison

• Outline of Coverage provides more in-depth summary

• PPO and HMO disclosures provide detailed policy terms and conditions prior to purchasing a plan

• Provider directory displays in-network providers

• Formulary shows prescription drug coverage tiers

Network AdequacyTDI reviews HMO, PPO, and EPO networks for adequacy:

•Direct and reasonable access to all classes of physicians and practitioners licensed to provide services covered by the plan

•Distance requirements, from any point in service area:

– Primary care: 30 miles (nonrural), 60 miles (rural)

– Specialty care: 75 miles (mental/behavioral considered specialty)

•Availability requirements

– Routine care

• Medical conditions: 3 weeks

• Behavioral health: 2 weeks

– Preventive care

• Child: 2 months (earlier if necessary per recommended schedule)

• Adult: 3 months

Complaints• Complaints are primary method by which TDI learns

of violations

• TDI investigates complaints and takes action to ensure Texas requirements are upheld

• Consumers or providers may file a complaint with TDI regarding an insurer, HMO, IRO, or URA

• Call TDI’s Consumer Help Line for assistance:

• Toll free: 1-800-252-3439

• Austin: 512-463-6515

• A formal complaint must be written (paper or electronic)

TDI Complaint Process1. Upon receipt, prioritize complaints according to nature, severity,

and industry impact; appropriately note confidential information

2. Respond to customer, forward to regulated entity, review response (due in 10 days), and research issue as necessary

3. Screen issues for referral:

• identify “frivolous,” justified, and unjustified complaints

• check for potential enforcement, fraud, or market conduct referrals

• check for consumer education issues

4. Finalize response to customer (30 days, on average)

• Respond with informational/educational content and copy regulated entity on TDI’s closing letter as appropriate

Market Conduct Exams• TDI can conduct a market conduct examination at

any time

• Typically, this would be triggered if TDI receives numerous complaints that demonstrate a pattern and indicate a potential violation

• In-depth audit of company procedures

• If TDI’s investigation reveals a violation, TDI may initiate an enforcement action

TDI Resources

• Consumers: texashealthoptions.com

• Providers: tdi.texas.gov/hprovider/index.html

• Health topics: www.tdi.texas.gov/health/index.html

• Complaints: tdi.texas.gov/consumer/complfrm.html

• Rules: tdi.texas.gov/rules/index.html

• Bulletins: tdi.texas.gov/bulletins/index.html

• eNews: tdi.texas.gov/alert/emailnews.html

Contact TDI• Consumer Protection Help Line: 1-800-252-3439

• Consumer Protection: consumerprotection@tdi.texas.gov

• Rachel Bowden: rachel.bowden@tdi.texas.gov

Questions?