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 vaseverino@lac.org or send her a private chat through the webinar platform.

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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 vaseverino@lac.org

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

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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.

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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

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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)

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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.

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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.

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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.

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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.

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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.

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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?

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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

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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

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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?

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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?

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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!

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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

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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

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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!)

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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 managedcarecomplaint@health.ny.gov104Cont..

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) 267-2323phig@cms.hhs.gov

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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) 267-2323phig@cms.hhs.gov

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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)

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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.

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