Technical Difficulties? Call (212) 243-1313 with technical
problems during the webinar 2
Slide 3
Who Is Your Presenter? Karla Lopez, Esq. Staff Attorney Legal
Action Center 3
Slide 4
Who Is the Legal Action Center? Non-profit law & policy
organization Anti-discrimination & privacy work Substance Use
Disorders HIV/AIDS Criminal Records Legal services, litigation,
policy, technical assistance 4
Slide 5
Help from Legal Action Center Our website has many resources
www.lac.org Call with questions about privacy or discrimination
relating to HIV/AIDS, substance use disorders, or criminal records
(212) 243-1313 Refer clients See next slide. 5
Slide 6
Help from Legal Action Center We provide free legal services,
including: Assistance with HIV testing & confidentiality
Assistance with claims of discrimination based on: HIV status
History of substance use disorder Criminal record: Rap sheet review
& error correction Certificates of Relief & Good Conduct
Job & housing discrimination 6
Slide 7
Todays Training Explains the federal parity law Tells NYS
service providers and advocates how they can take advantage of
their rights, and the rights of their clients/patients, under the
federal parity law We will take a 5 minute break halfway through
todays webinar 7
Slide 8
Get Credit for your Attendance! HAVE YOU REGISTERED? If you
havent officially registered with the NYS Department of Health AIDS
Institute, please do it now:
http://www.hivtrainingny.org/http://www.hivtrainingny.org/ If you
need assistance, contact Vanessa Severino at [email protected][email protected] 8
Slide 9
Todays Handouts This PowerPoint Summary of NY AG Assurance of
Discontinuance against MVP Health Care Summary of NY AG Assurance
of Discontinuance against Emblem Health Letter from NYS DOH re:
parity & Medicaid (10/2/2010) NYS Insurance Dept. Circular
Letter No. 20 (2009) NYS Dept. of Financial Svc. Insurance Circular
Letter No. 5 (2014) 9 Cont.
Slide 10
Todays Handouts, cont. Letter from Centers for Medicare &
Medicaid Services to State Health Officials (11/4/2009) Letter from
NYS DOH re: overdose prevention program (9/11/2014) Letter from NYS
DOH re: PReP (7/24/2014) 2014 Opiate Legislation Package: Bill
Summaries 10
POLL Do you work directly with clients or patients? Yes No
13
Slide 14
POLL If you do work directly with clients/patients, do you have
clients/patients with substance use disorders? Yes No 14
Slide 15
POLL If you do work directly with clients/patients, do you have
clients/patients with mental health issues? Yes No 15
Slide 16
POLL Have you noticed your patients/clients having more
difficulty getting insurance coverage for substance use disorder or
mental health treatment than for other kinds of medical and
surgical care? Yes No Dont know/cant answer 16
Slide 17
POLL How familiar are you with the federal parity law? Ive
never heard of it Ive heard of it but dont know much about it I
know a lot about it 17
Slide 18
Mental Health Parity & Addiction Equity Act of 2008 1.
Overview 2. Who Must Comply 3. What Does It Require 18
Slide 19
19
Slide 20
Federal Parity Law: Overview The Paul Wellstone & Pete
Domenici Mental Health Parity and Addiction Equity Act (MHPAEA),
often referred to as the federal parity law, became federal law in
October 2008, after 12 years of advocacy According to Congress, the
purpose of the federal parity law is to counter a history of
discrimination and stigma against mental illness and substance-
related disorders that has resulted in much less access to care.
20
Slide 21
Federal Parity Law: Overview The federal parity law requires
health insurance plans that cover mental health (MH) &
substance use disorder (SUD) benefits to cover them equally (at
parity) with other medical & surgical benefits 21
Slide 22
Federal Parity Law: Overview This means that it should no
longer be more difficult for a patient to have her addiction
treatment covered by her health insurance than to have her diabetes
treatment covered. 22
Slide 23
Federal Parity Law: Overview Note on State Law: Many states
have their own parity laws Todays webinar will focus on the federal
parity law, which applies to every state in the country New York
State has a state parity law (Timothys Law), but it only covers
mental health benefits, not substance use disorder benefits NYS
also recently passed a package of laws in response to the opioid
crisismore info on those new laws later 23
Slide 24
24
Slide 25
Federal Parity Law: Who Must Comply First, a few definitions.
Grandfathered plans are those that were in place on March 23, 2010
and have not made certain changes since then Non-grandfathered
plans are those that were created after March 23, 2010, or those
created before March 23, 2010 that have made certain changes since
then Marketplace refers to the health insurance exchanges &
marketplaces created by the Affordable Care Act (ACA) 25 Cont.
Slide 26
Federal Parity Law: Who Must Comply Definitions, cont.
Self-Insured plans are those where an employer pays directly for
its employees' health care claims, rather than purchasing a plan
from an insurance company; employers usually hire a third-party
insurance company for administrative services such as enrollment
and claims processing. Fully-Insured plans are those where an
employer purchases a health plan on the commercial market and pays
premiums to an insurance company to cover the cost of its employees
health care claims. 26
Slide 27
Federal Parity Law: Who Must Comply? Most private and public
health insurance plans must comply with the federal parity law,
including: Large group health plans (i.e., most plans offered by
private employers to their employees) Medicaid Managed Care plans
Medicaid Alternative Benefit Plans (ABPs), including those provided
to Medicaid expansion population Childrens Health Insurance Program
(CHIP) Individual & small group plans sold on the marketplace
Non-grandfathered individual & small group plans offered
outside the marketplace Grandfathered individual plans offered
outside the marketplace 27
Slide 28
Federal Parity Law: Who Must Comply? But, some health insurance
plans do not have to comply with parity, including: Medicare
Traditional (fee-for-service) Medicaid Plans that have successfully
applied for a cost-increase exemption Self-insured plans offered by
state & local government employers Grandfathered small group
plans offered outside the marketplace Church sponsored plans
Retiree-only plans TriCare 28
Slide 29
Federal Parity Law: Who Must Comply? Note on federal parity law
& ACA: The Affordable Care Act (ACA) expanded the reach of the
federal parity law by requiring additional types of health
insurance plans to comply with parity Not every type of plan listed
in the who must comply slide was covered by the 2008 parity law;
some were added in 2010 by the ACA 29
Slide 30
Federal Parity Law: Who Must Comply? Note on federal parity law
& ACA, cont. The federal parity law does not require health
insurance plans to cover MH & SUD benefits; it only imposes
requirements on plans that do choose to provide such benefits.
However, the Affordable Care Act (ACA) includes MH & SUD
benefits in its list of Essential Health Benefits, meaning certain
types of plansnamely plans sold to individuals & small groups
on the marketplace and Medicaid plans for the expansion population
under the ACAmust cover those benefits and cover them at parity
30
Slide 31
Federal Parity Law: Who Must Comply? Therefore, some plans must
provide MH & SUD benefits to comply with the ACA, and they must
provide the MH & SUD benefits equally with medical &
surgical benefits because of the federal parity law. 31
Slide 32
Summary: Who Must Comply? If offer MH/SUD, must comply with
parity Must offer MH/SUD, and comply with parity Not required to
offer MH/SUD or comply with parity Large group plans Medicaid
Managed Care plans Grandfathered individual plans offered outside
marketplace/exchange Individual & small group plans sold on
marketplace Non-grandfathered small group plans offered outside
marketplace Non-grandfathered individual plans offered outside
marketplace Medicaid ABPs CHIP (only required to offer MH) Medicare
Grandfathered small group plans offered outside marketplace Plans
w/cost increase exemption Church-sponsored Self-insured state &
local govt employers Retiree-only Tri-Care 32
Slide 33
33
Slide 34
Federal Parity Law: What Does It Require? The federal parity
law (MHPAEA) says: the financial requirements and treatment
limitations imposed by insurers on MH & SUD benefits cannot be
more restrictive than the predominant financial requirements and
treatment limitations that apply to substantially all medical &
surgical benefits. In essence: MH/SUD benefits, if provided, must
be provided equally with other medical/surgical benefits 34
Slide 35
Federal Parity Law: What Does It Require? What does all that
mean? 35
Slide 36
Federal Parity Law: What Does It Require? First, what are
financial requirements and treatment limitations? 36
Slide 37
Federal Parity Law: What Does It Require? What are financial
requirements? Deductibles Co-payments Co-insurance Out-of-pocket
maximums 37
Slide 38
Federal Parity Law: What Does It Require? What are treatment
limitations? There are 2 kinds of treatment limitations: 1.
Quantitative Treatment Limitations 2. Non-Quantitative Treatment
Limitations (NQTLs) 38 Cont.
Slide 39
Federal Parity Law: What Does It Require? What are treatment
limitations? Quantitative treatment limitations are those expressed
numerically, such as Limits on the number of days or visits covered
Limits on the frequency of treatment 39 Cont.
Slide 40
Federal Parity Law: What Does It Require? What are treatment
limitations, cont Non-Quantitative treatment limitations (NQTL) are
not expressed numerically, but otherwise limit scope/durationi.e.,
medical management tools: Medical necessity criteria
Preauthorization requirements Prescription drug formulary design
Fail-first or step therapy policies 40 Cont.
Slide 41
Federal Parity Law: What Does It Require? What are treatment
limitations, cont Non-Quantitative treatment limitations (NQTL),
cont Standards for provider admission to participate in- network
Determination of usual, customary, reasonable amounts Exclusions
based on failure to complete a course of treatment *Note: this is
not an exhaustive list 41
Slide 42
CASE STUDY: Question Jay visits a psychologist once per week.
His health insurance plan requires a $50 co-payment each time he
visits his psychologist. Is this co-payment either a financial
requirement or treatment limitation that is covered by the federal
parity law? 42
Slide 43
CASE STUDY: Possible Answers Yes No 43
Slide 44
CASE STUDY: Correct Answer Yes, co-payments (like the $50 Jay
must pay each time he sees his psychologist) are financial
requirements, and therefore they must comply with the federal
parity law. 44
Slide 45
45
Slide 46
Federal Parity Law: What Does It Require? Now that weve
discussed financial requirements & treatment limitations. How
do I know if they are more restrictive for MH/SUD benefits than for
other medical/surgical benefits? (Remember: The federal parity law
(MHPAEA) says the financial requirements and treatment limitations
imposed on MH & SUD benefits cannot be more restrictive than
the predominant financial requirements and treatment limitations
that apply to substantially all medical & surgical benefits.)
46
Slide 47
Federal Parity Law: What Does It Require? The federal parity
laws regulations require all of a plans MH/SUD benefits and all of
its medical/surgical benefits to be placed in one of 6
classifications, and provide a formula for comparing MH/SUD and
medical/surgical benefits within each classification. 6
classifications: 1. Inpatient, in-network 2. Inpatient,
out-of-network 3. Outpatient, in-network 4. Outpatient,
out-of-network 5. Emergency care 6. Prescription drugs 47
Slide 48
Federal Parity Law: What Does It Require? 6 Classifications,
cont MH/SUD benefits in a given classificationsuch as inpatient,
in-networkwill be compared with other medical/surgical benefits in
that same classification to determine whether the financial
requirements & treatment limitations on the MH/SUD benefits are
more restrictive. In other words, compare like with like. 48
Slide 49
CASE STUDY: Question Jay is wondering whether the $50
co-payment he is required to pay at his weekly visit to his
psychologist complies with the parity lawthat is, whether this
financial requirement for an MH/SUD benefit is equal to similar
medical/surgical benefits. Should Jay check to see whether the $50
co-payment for his psychologist visits is equal to: A. The
co-payment he makes when he visits his primary care physician, or
B. The co-payment he makes for a visit to the emergency room?
49
Slide 50
CASE STUDY: Possible Answers A. The co-payment he makes when he
visits his primary care physician B. The co-payment he makes for a
visit to the emergency room 50
Slide 51
CASE STUDY: Correct Answer A. The co-payment he makes when he
visits his primary care physician Jay first needs to find out how
his insurance plan classifies his psychologist visits, but they are
most likely in the outpatient category. Therefore, Jay would need
to compare his co-payment for the psychologistan outpatient visitto
his co-payment for outpatient visits on the medical/surgical side,
such as visits to a primary care physician. By contrast, a visit to
the emergency room would presumably fall into the emergency care
category, and therefore its co-payments should not be compared to
co- payments in the outpatient category. 51
Slide 52
CASE STUDY: Correct Answer, cont. Remember: Compare like with
like! 52 MH/SUDMedical/Surgical Inpatient Detoxification Inpatient
Appendicitis Outpatient Psychologist visit Outpatient Primary care
visit Emergency Care ER for overdose Emergency Care ER for broken
leg Prescription Drugs Suboxone Prescription Drugs Blood pressure
medication
Slide 53
Federal Parity Law: What Does It Require? 6 Classifications,
cont If a health plan offers MH/SUD benefits in any classification,
MH/SUD benefits must be provided in every classification in which
medical/surgical benefits are provided. 53
Slide 54
CASE STUDY: Question Glorias health insurance plan covers both
outpatient and inpatient treatment for medical/surgical ailments.
For example, it covers outpatient visits to her primary care doctor
when she gets sick, and inpatient stays at the hospital when she
has appendicitis and gives birth. Her plan also covers outpatient
MH/SUD treatment for example, outpatient addiction counseling.
However, her plan will not cover inpatient detoxification for her
addiction. Does Glorias plan meet the requirements of the federal
parity law? 54
Slide 55
CASE STUDY: Possible Answers Yes No 55
Slide 56
CASE STUDY: Correct Answer No, it probably does not meet the
requirements of the federal parity law (meaning it is probably
illegal). Because Glorias health plan offers MH/SUD benefits in any
classification (in this case, it offers them in the outpatient
classification), it must offer them in every classification in
which it offers medical/surgical benefits (in this case, both
outpatient and inpatient). 56
Slide 57
Federal Parity Law: What Does It Require? Once all of the
benefits have been put into one of the 6 classifications, how do
you compare financial requirements & treatment limitations for
MH/SUD vs. medical/surgical? (Remember: The federal parity law
(MHPAEA) says the financial requirements and treatment limitations
imposed on MH & SUD benefits cannot be more restrictive than
the predominant financial requirements and treatment limitations
that apply to substantially all medical & surgical benefits.)
57
Slide 58
Federal Parity Law: What Does It Require? For financial
requirements and quantitative treatment limitations, cannot impose
any on MH/SUD benefits that are separate from or more restrictive
than the predominant ones applied to substantially all
medical/surgical benefits in the same classification For
non-quantitative treatment limitations (NQTLs), cannot impose any
on MH/SUD that are not comparable to those used for
medical/surgical, and cannot apply them more stringently to MH/SUD
than medical/surgical 58
Slide 59
Federal Parity Law: What Does It Require? What does all that
mean? 59
Slide 60
Federal Parity Law: What Does It Require? What do I need to
know about predominant and substantially all? They are part of the
formula for comparing MH/SUD benefits with medical/surgical
benefits to determine whether they meet the requirements of the
parity law. You dont need to get bogged down in the details of the
formula. If you see something that looks like a violation of the
parity law, you can report it to the appropriate entity and they
will do the analysis using the formula. Well talk more about that
later. 60
Slide 61
Federal Parity Law: What Does It Require? Practices That Often
Violate Federal Parity Law: Having 1 deductible for MH/SUD services
and 1 for medical/surgical services that accumulate separately
Limits on the # of days or visits for MH/SUD treatment, when there
arent similar limits for medical/surgical Higher co-payments &
co-insurance for MH/SUD than for medical/surgical (e.g., charging a
specialist rate for MH/SUD outpatient visits, when a specialist
rate isnt charged for most medical/surgical outpatient visits) 61
Cont.
Slide 62
Federal Parity Law: What Does It Require? Practices That Often
Violate Parity, cont Requiring patient to fail first at MH/SUD
outpatient treatment before approving residential or inpatient
treatment (and not having similar policies for med/surgical)
Requiring MH/SUD patients to get prior authorization at earlier
stages of treatment or more frequently during treatment than
medical/surgical patients 62 Cont.
Slide 63
Federal Parity Law: What Does It Require? Practices That Often
Violate Parity, cont Excluding intermediate levels of MH/SUD care,
like residential treatment, from coverage, if the plan covers
intermediate care (like skilled nursing) for medical/surgical
Requiring MH/SUD patients to be treated in-state, but allowing
medical/surgical patients to be treated out-of- state Putting
yearly or lifetime limit on length of time patient can receive
methadone, buprenorphine, or naltrexone 63
Slide 64
CASE STUDY: Question Claires physician has recommended
inpatient treatment for her addiction. Claires insurance plan
requires pre-authorization for inpatient addiction treatment. When
Claire had inpatient treatment for salmonella, no pre-authorization
was required. Does Claires plan comply with the federal parity law?
64
Slide 65
CASE STUDY: Possible Answers Yes No 65
Slide 66
CASE STUDY: Correct Answer No, the plan probably does not
comply with parity. Pre-authorization requirements are a Non-
Quantitative Treatment Limitation (NQTL). Remember, plans cannot
impose any NQTLs on MH/SUD that are not comparable to those used
for medical/surgical. Here, the MH/SUD NQTL (pre-authorization) is
not comparable to the medical/surgical NQTL, in the inpatient
classification, because pre-authorization is required for Claires
inpatient addiction treatment but not for her inpatient salmonella
treatment. 66
Slide 67
CASE STUDY: Question Phil enters the hospital for an inpatient
detoxification from opioids that will last 7 days. His health plan
requires pre-authorization for inpatient addiction treatment and
also for inpatient medical/surgical treatment. When Phils physician
applies for pre-authorization for his 7-day inpatient detox, the
plan approves only one day at a time, requiring his physician to
re-apply each day in order to complete his treatment. When Phil
must spend a week in the hospital recovering from a surgical
procedure, his insurance plan pre- authorizes the whole 7 days.
Does Phils plan comply with the federal parity law? 67
Slide 68
CASE STUDY: Possible Answers Yes No 68
Slide 69
CASE STUDY: Correct Answer No, the plan probably does not
comply with parity law. Remember, plans cannot apply any NQTLs
(like pre- authorization requirements) more stringently to MH/SUD
than medical/surgical. Here, plan is applying the MH/SUD NQTL (pre-
authorization requirements) more stringently than the
medical/surgical NQTL, because it will approve only one day of
inpatient treatment at a time for Phils opioid detox, but will
approve a full 7 days at once for his surgical recovery. 69
Slide 70
A Note on the Polls Remember that there is a formula to
determine whether health insurance plans are complying with the
federal parity law. Generally, those who enforce the federal parity
law (mostly government regulators) are the ones who will apply the
formula to decide for sure whether a plan has violated the law. Our
polls dont go into that level of detail, but are more to give you a
general idea of things that probably violate the law so that you
can recognize them and bring them to the attention of regulators
& others. 70
Slide 71
71
Slide 72
We are more than half-way finished! Next up: How to enforce
rights under federal parity law 72
Federal Parity Law: Enforcing Rights Steps to Take: 1. Request
information from health insurance plan. 2. File internal appeal; if
denied, file external appeal. 3. If appeal(s) denied, contact
government agencies that enforce the law. 4. Additional option:
Lawsuit. Note: You are not necessarily required to file appeals
before contacting government agencies, but they will likely tell
you to do so when you contact them before they will get involved.
74
Slide 75
75
Slide 76
Enforcing Federal Parity Law: First, Request Information
Transparency Requirements: Providers & patients have the right
to certain information from health plans under the federal parity
law. 76 Cont.
Slide 77
Enforcing Federal Parity Law: First, Request Information
Transparency Requirements, cont. Most plans covered by the federal
parity law must provide, if you request it: Written explanation of
how non-quantitative treatment limitations (e.g., medical necessity
criteria) are applied to their medical/surgical & MH/SUD
benefits; Reason for denials of payment or reimbursement; Any
additional evidence used to make benefit determinations during
appeals. This info generally must be provided within 30 days of
request, and free of charge. 77
Slide 78
78
Slide 79
Enforcing Federal Parity Law: Second, File Appeals Internal
& External Appeals: Ask the health plan how to file appeals.
Look into expedited appeals if need be. Internal appeals are
generally conducted by the health plan, while external appeals in
NYS are conducted by the State Dept. of Financial Services:
http://www.dfs.ny.gov/insurance/extapp/extappqa.ht m
http://www.dfs.ny.gov/insurance/extapp/extappqa.ht m For both
internal & external appeals: Pay careful attention to
deadlines! 79
Slide 80
80
Slide 81
Enforcing Federal Parity Law: Third, Contact Govt. Agencies If
you think your patients health plan is violating the federal parity
law, you can complain to the government agencies that are tasked
with enforcing the law, or you can complain to the State Attorney
General. 81 Cont.
Slide 82
Enforcing Federal Parity Law: Third, Contact Govt. Agencies New
York State Attorney General: NYS AG is proactively enforcing the
federal parity law If you think a NYS health plan is violating
parity, you can call the AGs Health Care Bureau hotline: AG has
settled 3 cases against NYS health plans for parity violations so
far (Cigna, MVP Health Care, and Empire Health; MVP & Empire
administered behavioral health benefits through ValueOptions) 82
Cont. 1-800-428-9071
Slide 83
Enforcing Federal Parity Law: Third, Contact Govt. Agencies New
York State Attorney General, cont Examples of practices found by AG
to violate parity: Not covering residential MH/SUD treatment
Charging higher co-payments for outpatient mental health visits
than for outpatient primary care visits More frequent denials of
requests for pre-authorization & of claims for MH/SUD than for
medical/surgical Requiring (unofficially) that patients fail first
at outpatient MH/SUD treatment before approving inpatient 83
Cont.
Slide 84
Enforcing Federal Parity Law: Third, Contact Govt. Agencies New
York State Attorney General, cont Examples of violations, cont.
Approving only a few days of MH/SUD treatment at a time Requiring
MH/SUD providers to have treatment & discharge plans even for
outpatient treatment Having a certain # of psychotherapy visits
trigger special intensive utilization review Generic denial letters
Not using OASAS Level of Care Criteria to determine medical
necessity of SUD treatment 84
Slide 85
Enforcing Federal Parity Law: Third, Contact Govt. Agencies New
York State Attorney General, cont The AG can also enforce state
laws, like the state parity law (which only applies to MH), and
state laws regulating insurers 85
Slide 86
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Other Govt. Enforcement Options: The AG is just one option for
enforcing the parity law The federal parity law itself gives
enforcement authority to a variety of state and federal agencies
Different agencies enforce federal parity law for different types
of health plans Remember, it is advisable to appeal directly to the
insurance plan before going to a government agency 86 Cont.
Slide 87
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Medicaid Managed Care: For suspected parity violations by Medicaid
managed care plans (remember, traditional fee-for-service Medicaid
isnt covered by the federal parity law): Primary enforcement
responsibility: State Medicaid Director Jason Helgerson State
Medicaid Director, Deputy Commissioner State of New York,
Department of Health Empire State Plaza, Corning Tower, Room 1466
Albany, NY 12237 (518) 4743018 87 Cont.
Slide 88
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Medicaid Managed Care, cont If a State Medicaid Director is not
substantially enforcing federal parity, you can complain instead to
the U.S. Dept. of Health & Human Services about potential
parity violations by Medicaid managed care plans: U.S. Dept. of
Health & Human Services (877) 267-2323 [email protected] 88
Slide 89
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Individual & Small Group Plans: For suspected parity violations
by individual plans or small group plans: Primary enforcement
responsibility: State Insurance Commissioner Benjamin M. Lawsky
Commissioner NYS Dept. of Financial Services One State Street New
York, NY 10004 (212) 709-3500 89 Cont.
Slide 90
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Individual & Small Group Plans, cont If a State Insurance
Commissioner is not substantially enforcing federal parity, you can
complain to the U.S. Dept. of Health & Human Services instead
about potential parity violations by individual & small group
plans: U.S. Dept. of Health & Human Services (877) 267-2323
[email protected] 90
Slide 91
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Large Group Plans: For suspected parity violations by large group
plans, enforcement authority is shared between several agencies,
depending on whether the plan is self- insured or fully-insured. If
you dont know whether the plan is self- or fully- insured, you can
call the plan and ask, or you can just go ahead and complain about
the potential violation to one of the enforcement agencies (after
your appeals), who will coordinate amongst themselves to determine
who has authority. 91 Cont.
Slide 92
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Large Group Plans, cont For suspected parity violations by large
group plans: Remember: If you are unsure who to complain to, just
pick an agency and they should coordinate amongst themselves 92
Self-Insured Large Group Plans Fully-Insured Large Group Plans U.S.
Department of Labor (866) 444-3272 www.askebsa.dol.gov U.S.
Department of Treasury (202) 317-5500 State Insurance Commissioner
(see previous slide) U.S. Department of Health & Human Services
(see previous slide)
Slide 93
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Non-Federal Government Plans (Self-Insured): For suspected parity
violations by self-insured non- federal government plans (i.e.,
health insurance plans offered by state and local government
employers): U.S. Dept. of Health & Human Services (877)
267-2323 [email protected] 93
Slide 94
Enforcing Federal Parity Law: Third, Contact Govt. Agencies
Thats a lot of information! Dont worry too much about which
government agency has enforcement authority over which type of
plan; the federal government agencies have said they will help
patients & providers complaints get to the appropriate agency.
94
Slide 95
95
Slide 96
Enforcing Federal Parity Law: Additional OptionLawsuit A
patient can also enforce her rights under the federal parity law by
filing a lawsuit in court against the insurance company To pursue
this option, you and/or your patient should speak to an attorney
96
Slide 97
97
Slide 98
Some Relevant New York State Laws 98
Slide 99
Other Laws to Know Court-Ordered TreatmentInsurance Coverage:
NYS law requires Medicaid Managed Care plans in the state to cover
court-ordered treatment (if the plan would otherwise cover that
type of treatment) Example: Court orders defendant charged with
sale of controlled substances into outpatient addiction treatment.
If the persons Medicaid plan provides coverage for outpatient
addiction treatment generally, it would be required to cover that
type of treatment when ordered by a court. This law is found at New
York Social Services Law section 364-j(4)(r) 99
Slide 100
Other Laws to Know In June 2014, Gov. Cuomo signed a package of
bills into law to combat NYs opioid epidemic. The new laws require:
All insurance policies that are regulated by the NYS Dept. of
Financial Services and that provide hospital, major medical, or
other similar comprehensive coverage must provide inpatient and
outpatient services for the diagnosis & treatment of SUD,
including detoxification & rehabilitation services. Financial
requirements & treatment limitations of such coverage cannot be
more restrictive than medical/surgical, and the coverage must
comply with the federal parity law. 100 Cont.
Slide 101
Other Laws to Know New NY Laws to Combat Opioid Epidemic, cont
When NY insurers undertake utilization review for SUD treatment,
they must employ recognized evidence-based & peer reviewed
clinical review criteria. NY insurers must complete utilization
review within 24 hours of receiving a request for inpatient SUD
treatment, as long as the request is made 24 hours prior to
discharge from inpatient; cannot deny coverage while UR is pending
on basis of medical necessity or lack of prior authorization. 101
Cont.
Slide 102
Other Laws to Know New NY Laws to Combat Opioid Epidemic, cont
NY insurers must issue a decision within 24 hours of receiving an
appeal of a denial of inpatient SUD treatment; if appeal is filed
within 24 hours of the denial, insurer cannot deny treatment on the
basis of medical necessity or lack of prior authorization while the
appeal is pending. 102
Slide 103
Keep up with the Legal Action Center by following us on
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Slide 104
Please fill out Legal Action Centers survey about todays
webinar: https://www.surveymonkey.com/s/DPCG36X Please fill out the
AIDS Institutes survey on how it can improve its training website:
https://www.surveymonkey.com/s/howcanweimprove 104