Accessing Insurance Coverage for Substance Use & Mental
Health Treatment
Accessing Insurance Coverage for Substance Use & Mental
Health TreatmentThe Federal Parity LawNovember 18, 2015
1Technical Difficulties?Please email Vanessa Severino at
[email protected] or send her a private chat through the webinar
platform.
2
Who Is Your Presenter?Karla Lopez, Esq.Staff AttorneyLegal
Action Center
3Who Is the Legal Action Center?Non-profit law & policy
organization
Anti-discrimination & privacy workSubstance Use
DisordersHIV/AIDSCriminal Records
Legal services, litigation, policy, technical assistance
4Help from Legal Action CenterOur website has many
resourceswww.lac.org
Call with questions about privacy or discrimination relating to
HIV/AIDS, substance use disorders, or criminal records(212)
243-1313
Refer clientsSee next slide.
5Help from Legal Action CenterWe provide free legal services,
including:
Assistance with HIV testing & confidentiality
Assistance with claims of discrimination based on:
HIV statusHistory of substance use disorderCriminal record:
Rap sheet review & error correctionCertificates of Relief
& Good ConductJob & housing discrimination
6Todays TrainingExplains 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
webinar7
7Get 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/
If you need assistance, contact Vanessa Severino at
[email protected]
8Todays HandoutsThis PowerPointLetter 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)NYS Dept. of Financial Svc. Insurance Circular Letter No. 6
(2014)
9Cont.
Todays Handouts, cont.FEHB Program Carrier Letter No.
2008-17Letter from NYS DOH re: overdose prevention program
(9/11/2014)Letter from NYS DOH re: PReP (7/24/2014)2014 Opiate
Legislation Package: Bill Summaries10
Additional ResourcesLAC Parity Resources:
http://lac.org/resources/substance-use-resources/parity-health-care-access-resources/SAMHSAs
parity web page:
http://beta.samhsa.gov/health-reform/parity?from=carousel&position=1&date=10282013
Parity Implementation Coalition: https://parityispersonal.org/
Coalition for Whole Health: http://www.coalitionforwholehealth.org/
Parity Track: www.paritytrack.org 11Audience Poll12POLLHave 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?
YesNo Dont know/cant answer13POLLHow familiar are you with the
federal parity law?
Ive never heard of itIve heard of it but dont know much about
itI know a lot about it 14What Is the Federal Parity Law?Mental
Health Parity & Addiction Equity Act of 2008
OverviewWho Must ComplyWhat Does It RequireThe Details
15What Is the Federal Parity Law?1. Overview16Federal Parity
Law: OverviewThe 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.17
Federal Parity Law: OverviewThe 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
18
Federal Parity Law: OverviewThis 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.
19
Federal Parity Law: OverviewNote on State Law:
Many states have their own parity laws, including NYTodays
webinar will focus on the federal parity law, which applies to
every state in the countryNY also passed a package of laws in 2014
in response to the opioid crisis. The laws went into effect in
April 2015see handout.20
What Is the Federal Parity Law?2. Who Must Comply?21Federal
Parity Law:Who Must ComplyFirst, 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)22
Cont..Federal Parity Law:Who Must ComplyDefinitions, 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.23
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., plans offered by private
employers with 51+ employees)Medicaid Managed Care plansMedicaid
Alternative Benefit Plans (ABPs), including those provided to
Medicaid expansion populationChildrens Health Insurance Program
(CHIP)Individual plans
24
Cont..Grandfathered individual plans arent required to comply
with parity, but very few (if any) grandfathered individual plans
exist. Same goes for small group plans.24Federal Parity Law:Who
Must Comply?Who must comply, contd.
Small group plans sold on the New York State of Health
marketplace, or sold outside the marketplace and
non-grandfatheredState & local government employer plans (if
self-insured, can opt out)Church-sponsored plans (but can opt
out)Federal government employer plans (OPM guidancesee handout)
25
State & local govt plans that are self-insured can opt-out
of parity, but dont know of any in NY that have opted out25Federal
Parity Law:Who Must Comply?But, some health insurance plans do not
have to comply with parity, including:MedicareTraditional
(fee-for-service) MedicaidPlans that have successfully applied for
a cost-increase exemption (dont know of any in NYS)Grandfathered
small group plans offered outside the marketplace (very few
exist)Retiree-only plansTriCare26
26Federal 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
ACA27
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
parity28
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.
29Summary: Who Must Comply?If offer MH/SUD, must comply with
parityMust offer MH/SUD, and comply with parityNot required to
comply with parity**Large group plansMedicaid Managed Care
plansGrandfathered individual plans offered outside
marketplace/exchangeState & local government
plans*Church-sponsored plans*Federal govt. plans
*May opt outIndividual & small group plans sold on
marketplaceNon-grandfathered small group & individual plans
offered outside marketplaceMedicaid ABPsMedicareTraditional
(fee-for-service) MedicaidGrandfathered small group plans offered
outside marketplacePlans w/cost increase
exemptionRetiree-onlyTri-Care
**Note: these plans may be required to comply with state parity
or other laws30What Is the Federal Parity Law?3. What Does It
Require?31Federal Parity Law:What Does It Require?The federal
parity law requires that financial requirements and treatment
limitations be no more restrictive for MH/SUD benefits than for
medical/surgical benefits.
32
Federal Parity Law:What Does It Require?What are financial
requirements and treatment limitations?33
Federal Parity Law:What Does It Require?What are financial
requirements?
DeductiblesCo-paymentsCo-insuranceOut-of-pocket maximums34
34Federal Parity Law:What Does It Require?What are treatment
limitations?
There are 2 kinds of treatment limitations:
Quantitative Treatment Limitations
Non-Quantitative Treatment Limitations (NQTLs)
35Cont..35Federal 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 treatment36Cont..
36Federal 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 criteriaPreauthorization
requirementsPrescription drug formulary designFail-first or step
therapy policies37
Cont..37Federal Parity Law:What Does It Require?What are
treatment limitations, cont
Non-Quantitative treatment limitations (NQTL), cont.
Standards for provider admission to participate
in-networkDetermination of usual, customary, reasonable
amountsExclusions based on failure to complete a course of
treatmentGeographic limitations
*Note: this is not an exhaustive list38
38CASE STUDY: QuestionJay 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 a financial requirement or treatment
limitation that is covered by the federal parity law?39
CASE STUDY: Possible AnswersYes, it is a financial
requirement.Yes, it is a treatment limitation.No, it is not a
financial requirement or treatment limitation.40CASE STUDY: Correct
AnswerYes, it is a financial requirement. 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. 41Federal Parity Law:What Does It Require?Now you know
what financial requirements and treatment limitations are so what
does the law say about them specifically?42
Federal Parity Law:What Does It Require?First, plans may not
have separate financial requirements or treatment limitations that
apply only to MH/SUD benefits.43
CASE STUDY: QuestionCarries health plan imposes a $500
deductible on MH/SUD benefits. The plan does not impose a
deductible on medical/surgical benefits.
Does this violate the federal parity law?44
CASE STUDY: Possible AnswersYes, it violates the law.No, it does
not violate the law.45CASE STUDY: Correct AnswerYes, this violates
the federal parity law. Carries plan has a separate financial
requirementthe deductiblethat applies only to MH/SUD benefits and
not to medical surgical benefits. This is not allowed under the
federal parity law.46Federal Parity Law:What Does It
Require?Second, plans must provide out-of-network benefits for
MH/SUD services if they provide them for medical/surgical
benefits.47
CASE STUDY: QuestionQuinns health plan allows him to visit both
in-network and out-of-network providers for medical/surgical needs
(for example, an in-network or out-of-network neurologist).
However, his plan only allows him to visit in-network health care
providers for MH/SUD treatment (for example, only in-network
psychiatrists). Does Quinns plan comply with the federal parity
law?48
CASE STUDY: Possible AnswersYes, it complies.No, it does not
comply.49CASE STUDY: Correct AnswerB. No, this likely does not
comply with the federal parity law.* The law says if a plan
provides out-of-network benefits for medical/surgical services
(like the neurologist), it must provide out-of-network benefits for
MH/SUD services (like the psychiatrist). Quinns plan is not
following this requirement of the law.
*It likely does not comply, because more information is needed
to say for sure.50Federal Parity Law:What Does It Require?Third,
plans may not apply financial requirements or treatment limitations
to MH or SUD benefits that are more restrictive than the
predominant financial requirements and treatment limitations
applied to substantially all medical/surgical benefits.51
Federal Parity Law:What Does It Require?What does all that
mean?
We are going to talk a lot about this one.
52CASE STUDY: QuestionSauls health plan only allows 30
psychologist visits per year. There is no similar visit limit on
the medical/surgical side (for example, he can visit his primary
care doctor as often as he wants). Does Sauls plan comply with the
federal parity law?53
CASE STUDY: Possible AnswersYes, it complies.No, it does not
comply.54CASE STUDY: Correct AnswerB. No, this likely* does not
comply with the federal parity law. Sauls plan is placing a
treatment limitation (visit limits) on MH/SUD benefits (psychology
services) that it is not placing on medical/surgical benefits
(primary care). Therefore, the plan is applying a treatment
limitation to MH/SUD that is likely more restrictive than what its
applying to medical/surgical.
*It likely does not comply, because more information is needed
to say for sure. This will be discussed in more detail later in the
webinar.55
Time for a 5 minute break!56
What Is the Federal Parity Law?4. The Details57Federal Parity
Law:The DetailsRemember, the federal parity law says plans:may not
apply financial requirements or treatment limitations to MH or SUD
benefits that are more restrictive than the predominant financial
requirements and treatment limitations applied to substantially all
medical or surgical benefits.
What does that mean?58
Federal Parity Law:The DetailsHow do you know if financial
requirements & treatment limitations are more restrictive for
MH/SUD benefits than for other medical/surgical benefits?59
Federal Parity Law:The DetailsThe 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.
MH/SUD benefits are compared to medical/surgical benefits within
the same classification.
60
60Federal Parity Law:The Details6 classifications:Inpatient,
in-networkInpatient, out-of-networkOutpatient,
in-networkOutpatient, out-of-networkEmergency carePrescription
drugs
Note: For Medicaid & CHP, only 4 categories, because no
in-network/out-of-network distinction.
61
61Federal Parity Law:The Details6 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.
62
CASE STUDY: QuestionJay 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:The co-payment
he makes when he visits his primary care physician, orThe
co-payment he makes for a visit to the emergency room?63
CASE STUDY: Correct AnswerThe 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 when he is sick. 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.64CASE STUDY: Correct
Answer, cont.Remember: Compare like with like!
65MH/SUDMedical/SurgicalInpatientDetoxification
InpatientAppendicitis OutpatientPsychologist visitOutpatientPrimary
care visit when sickEmergency CareER for overdoseEmergency CareER
for broken legPrescription DrugsSuboxonePrescription DrugsBlood
pressure medication
Federal Parity Law:The Details6 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.
66
CASE STUDY: QuestionGlorias 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. Her plan also covers outpatient MH/SUD
treatmentfor 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?67
CASE STUDY: Possible AnswersYes, it meets the requirements of
the law.No, it does not meet the requirements of the law.68CASE
STUDY: Correct AnswerB. 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).
*It probably does not comply, because more information is needed
to say for sure.69Federal Parity Law:The DetailsOnce 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 to figure out if they are more
restrictive for MH/SUD?
70
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
71
71Federal Parity Law:The DetailsWhat does all that mean?72
Federal Parity Law:What Does It Require?What do I need to know
about predominant and substantially all?
They are part of a mathematical formula created by the law for
comparing MH/SUD benefits with medical/surgical benefits.
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.73
Federal Parity Law:The DetailsFor 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
74
74CASE STUDY: QuestionFrannies health plan requires her to get
prior authorization that a treatment is medically necessary for all
inpatient medical/surgical benefits and all inpatient MH/SUD
benefits. In practice, her plan routinely approves seven days of
inpatient benefits for medical/surgical conditions , after which
the patient's attending provider must submit a treatment plan for
approval. On the other hand, Frannies health plan routinely
approves only one day of inpatient MH/SUD benefits, after which her
attending provider must submit a treatment plan for approval.Does
Frannies plan violate the federal parity law?
75
CASE STUDY: Possible AnswersYes, it violates the law.No, it does
not violate the law.76CASE STUDY: Correct AnswerYes, it violates
the law.
Frannies plan is applying a stricter non-quantitative treatment
limitation in practice to MH/SUD benefits than is applied to
medical/surgical benefits.
Even if a NQTL is equal on paper, if it is applied more
stringently in practice it can still violate the law. 77CASE STUDY:
QuestionOttos health plan applies concurrent review to types of
inpatient care where the length of stay tends to vary greatly. The
plan uses a mathematical formula to determine which types of
inpatient care have a lot of variation. In practice, after applying
the formula, the plan applies concurrent review to 60 percent of
MH/SUD conditions, but only 30 percent of medical/surgical
conditions, because the formula found more variation in MH/SUD
inpatient stays than in medical/surgical.Does Ottos plan violate
the federal parity law?
78
CASE STUDY: Possible AnswersYes, it violates the law.No, it does
not violate the law.79CASE STUDY: Correct AnswerB. No, it does not
violate the law.
Ottos health plan complies with the federal parity law because
the evidentiary standard used by the plan is applied no more
stringently for MH/SUD benefits than for medical/surgical benefits,
even though it results in an overall difference in the application
of concurrent review for mental health conditions or substance use
disorders than for medical/surgical conditions.
80CASE STUDY: QuestionLukes health plan automatically excludes
coverage for inpatient SUD treatment in any setting outside of a
hospital (such as a freestanding or residential treatment center).
For inpatient treatment outside of a hospital for other conditions
(including freestanding or residential treatment centers prescribed
for mental health conditions, as well as for medical/surgical
conditions), the plan will provide coverage if the prescribing
physician obtains authorization from the plan that the inpatient
treatment is medically appropriate for the individual, based on
clinically appropriate standards of care.Does Lukes plan violate
the federal parity law?81
CASE STUDY: Possible AnswersYes, it violates the law.No, it does
not violate the law.82CASE STUDY: Correct AnswerYes, it violates
the law.
Although the same non-quantitative treatment limitationmedical
appropriatenessis applied to both MH/SUD benefits and
medical/surgical benefits, the plan's unconditional exclusion of
SUD treatment in any setting outside of a hospital is not
comparable to the conditional exclusion of inpatient treatment
outside of a hospital for other conditions.83Federal Parity Law:The
DetailsThis stuff is confusingif the details get overwhelming, just
look for the RED FLAGS!
84
Federal Parity Law:The DetailsRed Flags:
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)85Cont..
Federal Parity Law:The DetailsRed Flags, 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
86Cont.
Federal Parity Law:The DetailsRed Flags, 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
87
Cont.Federal Parity Law:The DetailsRed Flags, cont.
Putting yearly or lifetime limit on length of time patient can
receive methadone, buprenorphine, or naltrexoneor not covering
those medications at allRefusing to cover MH/SUD treatment because
patient failed to complete previous treatment or because the
patient is not improvingRefusal to provide information, like
medical necessity criteria, when you request it (more on this
coming up!)
88
Federal Parity Law:The DetailsIf you see a red flag and dont
want to get bogged down in the complexities of the federal parity
law, just report it!
Next up: What to do if you see a red flag or think a plan may be
violating the federal parity law..89
How Can Patients & Providers Enforce Their Rights under the
Federal Parity Law?Transparency RequirementsAppealsGovernment
EnforcementLawsuit90Federal Parity Law:Enforcing RightsSteps to
Take:Request information from health insurance plan.File internal
appeal; if denied, file external appeal.If appeal(s) denied,
contact government agencies that enforce the law.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.91
How To Enforce Rights?1. Transparency Requirements92Enforcing
Federal Parity Law:First, Request InformationTransparency
Requirements:
Providers & patients have the right to certain information
from health plans under the federal parity law.93Cont..
93Enforcing Federal Parity Law:First, Request
InformationTransparency Requirements, cont..Most plans covered by
the federal parity law must provide, if you request it:Criteria
used to make medical necessity decisionsboth MH/SUD and
medical/surgicalWritten 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.94
Generally must be provided within 30 days and free of
charge94How To Enforce Rights?2. Appeals95Enforcing Federal Parity
Law:Second, File AppealsInternal & External Appeals:Ask the
health plan how to file appeals. Look into expedited appeals if
need be.Internal appeals: conducted by the health planExternal
appeals: conducted by 3rd party reviewers (not the plan). In NYS
most external appeals are conducted by the State Dept. of Financial
Services.For both internal & external appeals: Pay careful
attention to deadlines!96
Cont..96Enforcing Federal Parity Law:Second, File
AppealsInternal & External Appeals, cont..
Community Health Advocates can help with appeals:
1-888-614-5400
Tip: Be sure to specifically mention state and federal parity
laws in your appealsotherwise, those laws may not be considered,
and courts may not be able to consider them later on if you want
them review the outcome of your appeals.97
97How To Enforce Rights?3. Government Agencies98Enforcing
Federal Parity Law:Third, Contact Govt. AgenciesIf you think a
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.99
Cont..Enforcing Federal Parity Law:Third, Contact Govt.
AgenciesNew 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:
100Cont..1-800-428-9071
Enforcing Federal Parity Law:Third, Contact Govt. AgenciesNYS
Attorney General, cont...AG has settled 5 cases against NYS health
plans for parity violations so far (Cigna, MVP Health Care, Empire
Health, ValueOptions/BeaconHealthOptions, & Excellus)For
information about what the AG said violated the parity law, as well
as copies of the AGs settlement agreements,
visit:http://lac.org/resources/substance-use-resources/parity-health-care-access-resources/new-york-attorney-general-parity-enforcement/
101
Enforcing Federal Parity Law:Third, Contact Govt. AgenciesNew
York State Attorney General, cont.
The AG can also enforce other federal laws (like the ACA) and
state laws (like the state parity law).102
Enforcing Federal Parity Law:Third, Contact Govt. AgenciesOther
Govt. Enforcement Options:
The AG is just one option for enforcing the parity lawThe
federal parity law itself gives enforcement authority to a variety
of state and federal agenciesDifferent agencies enforce federal
parity law for different types of health plansRemember, it is
advisable to appeal directly to the insurance plan before going to
a government agency103
Cont..Enforcing Federal Parity Law:Third, Contact Govt.
AgenciesMedicaid Managed Care & CHP:
For suspected parity violationsPrimary enforcement
responsibility: State Medicaid Director. You can complain to: NY
Dept. of Health1-800-206-8125
[email protected]..
104Enforcing Federal Parity Law:Third, Contact Govt.
AgenciesMedicaid Managed Care & CHP, 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)
[email protected]
105
105Enforcing Federal Parity Law:Third, Contact Govt.
AgenciesIndividual & Small Group Plans:For suspected parity
violations.Primary enforcement responsibility: State Insurance
CommissionerYou can complain to: NY Dept. of Financial
Services1-800-342-3736Online complaint:
http://www.dfs.ny.gov/consumer/fileacomplaint.htm 106Cont..
106Enforcing Federal Parity Law:Third, Contact Govt.
AgenciesIndividual & 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)
[email protected]
107
Enforcing Federal Parity Law:Third, Contact Govt. AgenciesLarge
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.108Cont..Enforcing Federal Parity Law:Third, Contact
Govt. AgenciesLarge 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
109Self-Insured Large Group PlansFully-Insured Large Group
PlansU.S. Department of Labor(866) 444-3272www.askebsa.dol.gov
U.S. Department of Treasury(202) 317-5500State Insurance
Commissioner(see previous slide)
U.S. Department of Health & Human Services(see previous
slide)Enforcing Federal Parity Law:Third, Contact Govt.
AgenciesState & Local Government Plans :Depends on whether
self- or fully-insured
110Self-insured state & local govt. plansFully-insured state
& local govt. plansU.S. Department of Labor(866)
444-3272www.askebsa.dol.gov
State Insurance Commissioner(see previous slide)
U.S. Department of Treasury(202) 317-5500U.S. Department of
Health & Human Services(see previous slide)
Enforcing Federal Parity Law:Third, Contact Govt. AgenciesThats
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.111
Enforcing Federal Parity Law:Third, Contact Govt. AgenciesA few
tips for complaining to govt. agencies:
Mention the federal parity law specifically in your
complaintotherwise the agency may not look for parity violationsAsk
the government agency to provide you with its findings/conclusions
in writing112How To Enforce Rights?4. Lawsuits113Enforcing Federal
Parity Law:Additional OptionLawsuit Depending on what type of
health plan she has, a patient may be able to enforce her rights
under the federal parity law by filing a lawsuit in court against
the insurance companyTo pursue this option, you and/or your patient
should speak to an attorneyNew York State Psychiatric Association
v. United Healthcare114
Other Laws to Know(see handouts for more info)115Other Laws to
KnowCourt-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)
116
116Other Laws to KnowIn 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.
117Cont..
117Other Laws to KnowNew 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.118Cont..
Other Laws to KnowNew 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.
119
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