Mental Health Parity

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Mental Health Parity Addiction
Equity Community Forum
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Presenters

• Katharine Ligon, M.S.W.
• Policy Analyst, Center for Public Policy
  Priorities
• Rachel Bowden, MPAff, PMP
• Program Specialist VI, Texas Department of
  Insurance

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Agenda

• History and Context Prior to Federal Parity Law
• Overview of Federal Parity Law
• Overview of Texas Parity Law
• Parity Law and the Affordable Care Act
• Parity Advocacy Next Steps
• Texas Department of Insurance Scope of Regulatory
  Authority and Regulatory Approach
• QA

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Profile Mental Health and Substance Use in Texas

• Adults
• 17 million working-age adults (ages 18 to 64
  years) in Texas
• 3.7 million some type of mental disorder
• 848,000 adults had a Serious Mental Illness
• 441,000 adults had a Serious and Persistent
  Mental Illness
• 1.7 million adults had a chemical dependency
• Children and Adolescents
• 3.2 million Texas children between ages 9 to 17
  years in 2012
• 634,000 children/adolescents had some type of
  diagnosable mental disorder.
• 159,000 children/adolescents had a Serious
  Emotional Disturbance
• Texas DSHS estimated that in 2010 more than
  174,000 Texas adolescents (ages 12 to 17) had a
  chemical dependency.

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Prior to Mental Health Parity and the Affordable
Care Act

• Barriers for Individuals with Mental Illness
  and/or Substance Use Disorders
• Discriminatory benefits for MH/SU
• Denial of health insurance for pre-existing
  conditions
• Annual caps of dollar amount for health care
• Lifetime dollar amount limits on health insurance
  benefits
• Higher premiums for illness
• Limited coverage for certain illness

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Timeline of Mental Health Parityin the United
States
Senators Domenici and Wellstone elevated mental
health parity on the public agenda consumer
advocates characterized lack of parity as
discrimination.
Deinstitutionalization begins, creating a modest
incentive for private insurers to cover services
not paid for by the public sector.
The Federal Employees Health Benefits Program
allows participating plans to reduce their mental
health benefits.
President Kennedy urged the Federal Employees
Health Benefits Program to cover psychiatric
illnesses comparably to medical conditions.
Healthcare costs increased dramatically and
mental health coverage was dropped or reduced by
many employers to try to reduce healthcare
insurance costs.
Sources Barry, C. L., Huskamp, H. A.,
Goldham, H. H. (2010). A political history of
federal mental health and addiction insurance
parity. The Milbank Quarterly A
Multidisciplinary of Population Health and Health
Policy, 88(3), 404-433. Quass, L. (2012).
Federal efforts to achieve mental health parity
A step in the right direction, but discrimination
remains. Legislation and Policy Brief, 4(1).
35-72.
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Federal Mental Health Parity

• Mental Health Parity Act of 1996
• Equated aggregate lifetime limits and annual
  limits for mental health benefits with limits for
  medical/surgical benefits
• Applied to group health plans and health
  insurance issuers
• No mandate for MH/SU benefits
• Did not apply to coverage for substance use or
  chemical dependency

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Timeline of Mental Health Parityin the United
States (contd)
President Bush stated support for mental health
parity
Mental Health Parity and Addiction Equity Act
(MHPAEA) passes
Mental Health Parity Act (MHPA) passes
At the first White House Conference on Mental
Health, President Clinton announced mental health
and substance use parity in Federal Employees
Health Benefits Plan
The New Freedom Commission on Mental Healths
final report recommended mental health parity
Sources Barry, C. L., Huskamp, H. A.,
Goldham, H. H. (2010). A political history of
federal mental health and addiction insurance
parity. The Milbank Quarterly A
Multidisciplinary of Population Health and Health
Policy, 88(3), 404-433. Quass, L. (2012).
Federal efforts to achieve mental health parity
A step in the right direction, but discrimination
remains. Legislation and Policy Brief, 4(1).
35-72.
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Federal Mental Health Parity

• Wellstone-Domenici Mental Health Parity and
  Addiction Equity Act of 2008 (MHPAEA)
• Federal oversight MH Parity
• Department of Treasury
• Department of Labor
• Department of Health and Human Services
• Timeline of Rules
• 2009 - Proposed Rules with request for public
  comments
• February 2010 Interim Final Rules released
• April 2010 majority of Interim Rules became
  effective (as if law)
• November 2013 Rules finalized
• July 2014 Rules effective
• TBD Rules for Medicaid managed-care plans

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Federal Mental Health Parity

• MHPAEA Implementation
• Requires the coverage terms for MH/SU benefits be
  no more restrictive than the coverage terms for
  medical/surgical services
• Financial requirements copays, coinsurance,
  deductibles
• Treatment limitations of outpatient visits,
  of inpatient days
• Eliminates annual and lifetime dollar limits for
  MH/SU benefits
• Allows comparison of MH/SU and medical
  intermediate levels of care (e.g. RTC or
  intensive outpatient treatment)
• Health plan transparency and greater access to
  information

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Federal Mental Health Parity

• MHPAEA Implementation
• Employer-based plans with 50 full-time employees
• Small employers that offer MH/SU coverage do not
  have to meet parity Except plans purchased
  through the ACA Marketplace
• Applies to group health plans and health
  insurance issuers that choose to offer MH/SU
  coverage
• Does not require plans to provide MH/SU benefits
  and coverage of specific diagnoses
• Applies to Medicaid and CHIP managed-care plans
• Does not apply to Medicare is not required to
  comply with federal parity to any extent

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Federal Mental Health Parity

• MHPAEA Implementation
• Classification of Benefits
• Cumulative Financial Requirements deductibles
  and out-of-pocket limits must combine both
  medical and MH/SU benefits
• Quantitative Treatment Limits outpatient
  visits
• Non-Quantitative Treatment Limits (NQTLs)
  pre-authorization of services, utilization
  reviews, Rx drug formulary design, fail-first
  policies

Inpatient / In-network Inpatient / Out-of-network
Outpatient / In-network Outpatient / Out-of-network
Emergency Care Prescription Drugs
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Texas Mental Health Parity

• Texas Department of Insurance Parity Rules
• In 2011, TDI adopted final rules related to
  MHPAEA of 2008 Financial and treatment
  limitations can be no more restrictive for MH/SU
  benefits than for medical benefits
• Do not address Federal Parity Rules (i.e.
  non-quantitative treatment limits)
• Maintains that large employers do not have to
  provide MH/SU benefits, except SMI coverage under
  the Texas Insurance Code
• Maintains that issuers must offer small employers
  SMI benefits

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Texas Substance Use Parity

• Texas Department of Insurance Parity Rules
• Mandates coverage for the necessary care and
  treatment of chemical dependency for employers of
  over 250 employees
• Coverage may not be less favorable than that
  provided for physical illness
• Coverage shall be subject to the same durational
  limits, dollar limits, deductibles and
  coinsurance factors that apply to coverage
  provided of physical illness
• Required coverage is limited to a lifetime
  maximum of three separate treatment series for
  each covered individual
• Requires standards be set up for use by insurers,
  other third-party reimbursement sources and
  chemical dependency treatment centers

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Texas Mental Health Benefits

• Coverage for Serious Mental Illnesses (SMI) and
  Other Disorders
• Large employer groups must provide SMI coverage
• Health insurance issuer must offer small employer
  groups SMI coverage
• Serious Mental Illness coverage
• Quantitative treatments at least 45 inpatient
  days 60 outpatient visits
• Prohibits lifetime limits on the inpatient days
  or outpatient visits
• Requires financial limitations be same for
  medical care

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ACA Extends MH Parity

• The ACA is ensuring that in 2014, most health
  insurance policies will cover 10 Essential Health
  Benefits.
• This means all health conditions should get the
  coverage they need!

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ACA Extends MH Parity
Plans must provide MH/SU benefits equal to
medical benefits including higher out-of-pocket
cost, preauthorization of services, utilization
reviews, or a narrower application of medical
necessity
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Texas Parity Enforcement

• Oversight and Compliance
• States do not need to enact separate legislation
  to enforce federal parity
• Some states have refused to adhere to MHPAEA
  without adopting state statute
• The Federal departments are working with states
  to follow federal law
• TDI does approve all group plans prior to being
  offered by Health Insurance Issuers
• TDI is responsive versus proactive

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Texas Parity Advocacy

• Categories of Advocacy
• Regulatory
• Consumer
• Provider
• Legislative

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Texas Parity Advocacy

• Regulatory Next Steps
• Ensuring oversight and compliance through the
  Texas Department of Insurance (TDI) and Health
  and Human Services Commission (HHSC)
• Request updated TX parity rules to address
  Federal Interim and Final Rules and ACA rules
• Work with TDI to ensure consumer complaint
  process is effective and complaints are being
  resolved appropriately

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Texas Parity Advocacy

• Consumer Education Next Steps
• Work through the DSHS Council for Advising and
  Planning (CAP) for the Prevention and Treatment
  of Mental and Substance Use Disorders
• Make Texas-specific parity information widely
  available to health insurance consumers
• Texas Mental Health Parity Toolkit
• What is parity?
• How do I know if my plan meets parity?
• How do I complete the complaint process if I
  think my plan is not in compliance with parity?

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Texas Department of Insurance

• How does the Texas Department of Insurance
  support parity in insurance coverage of mental
  health and substance use disorder services?
• TDI scope of regulatory authority
• Limited to fully insured private coverage
• TDI regulatory approach
• Form review
• Network adequacy
• Complaints

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TDIs Regulatory Scope

• TDIs authority is limited
• In scope fully insured individual and
  employer health insurance plans and HMOs
• Out of scope self-funded employer plans
  (employer bears risk) are regulated by the
  Department of Labor and ERISA
• Medicaid/CHIP TDI regulates network adequacy
  for participating managed care organizations
• Medicare TDI regulates Medicare Supplement
  plans

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Texans by Coverage Type
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TDI-Regulated Market
TDI only regulates fully insured individual and
employer coverage
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Does TDI Regulate a Plan?

• If TDI or DOI is on the insurance card
• YES

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Mission

• TDIs mission is to protect insurance consumers
  by
• regulating the insurance industry fairly and
  diligently
• promoting a stable and competitive market
• providing information that makes a difference

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Approach

• To regulate health insurance, TDI
• reviews and approves policies before they are
  sold
• reviews HMO, PPO, and EPO networks
• investigates complaints
• initiates market conduct exams when warranted

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Form Review

• TDI reviews policy forms for compliance with
  Texas requirements
• Checklists www.tdi.texas.gov/forms/form10accident
  .html
• Texas requirements for group health plans
• Chemical dependency mandated benefit (TIC Ch.
  1368)
• Serious mental illness mandate for large group
  plans, mandated offer for small group plans (TIC
  Ch. 1355, Subchapter A)
• Parity for mental health and substance use
  disorder benefits in large group plans (28 TAC
  Chapter 21, Subchapter P)

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Form Review
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Federal Review

• Federal regulators review individual and small
  group health plans for ACA requirements
• Required categories of essential health benefits
  include mental health and substance use disorder
  services
• EHB rules require provision of MH/SUD services to
  comply with parity
• EHB benchmark plan complies with Texas chemical
  dependency mandated benefit and includes serious
  mental illness coverage
• Federal EHB extends Texas requirements to
  individual market

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Understanding Coverage

• TexasHealthOptions.com provides a guide to help
  consumers understand insurance documents,
  cost-sharing, networks, and balance billing
• TDI has resources to explain which benefits
  should be covered by all plans
• Mandated benefits chart
• www.tdi.texas.gov/hmo/documents/manhealthben.pdf
• EHB benchmark plan summary chart
• www.texashealthoptions.com/cp2/healthcare.html

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Policy Documents

• Your insurance policy is the primary source for
  understanding what is covered and how its
  covered (cost sharing, prior authorization, etc.)
• Summary of Benefits and Coverage provides a
  standardized plan summary for comparison
• Outline of Coverage provides more in-depth
  summary
• PPO and HMO disclosures provide detailed policy
  terms and conditions prior to purchasing a plan
• Provider directory displays in-network providers
• Formulary shows prescription drug coverage tiers

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Network Adequacy

• TDI reviews HMO, PPO, and EPO networks for
  adequacy
• Direct and reasonable access to all classes of
  physicians and practitioners licensed to provide
  services covered by the plan
• Distance requirements, from any point in service
  area
• Primary care 30 miles (nonrural), 60 miles
  (rural)
• Specialty care 75 miles (mental/behavioral
  considered specialty)
• Availability requirements
• Routine care
• Medical conditions 3 weeks
• Behavioral health 2 weeks
• Preventive care
• Child 2 months (earlier if necessary per
  recommended schedule)
• Adult 3 months

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Complaints

• Complaints are primary method by which TDI learns
  of violations
• TDI investigates complaints and takes action to
  ensure Texas requirements are upheld
• Consumers or providers may file a complaint with
  TDI regarding an insurer, HMO, IRO, or URA
• Call TDIs Consumer Help Line for assistance
• Toll free 1-800-252-3439
• Austin 512-463-6515
• A formal complaint must be written (paper or
  electronic)

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TDI Complaint Process

• Upon receipt, prioritize complaints according to
  nature, severity, and industry impact
  appropriately note confidential information
• Respond to customer, forward to regulated entity,
  review response (due in 10 days), and research
  issue as necessary
• Screen issues for referral
• identify frivolous, justified, and unjustified
  complaints
• check for potential enforcement, fraud, or market
  conduct referrals
• check for consumer education issues
• Finalize response to customer (30 days, on
  average)
• Respond with informational/educational content
  and copy regulated entity on TDIs closing letter
  as appropriate

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Market Conduct Exams

• TDI can conduct a market conduct examination at
  any time
• Typically, this would be triggered if TDI
  receives numerous complaints that demonstrate a
  pattern and indicate a potential violation
• In-depth audit of company procedures
• If TDIs investigation reveals a violation, TDI
  may initiate an enforcement action

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TDI Resources

• Consumers texashealthoptions.com
• Providers tdi.texas.gov/hprovider/index.html
• Health topics www.tdi.texas.gov/health/index.html
  
• Complaints tdi.texas.gov/consumer/complfrm.html
• Rules tdi.texas.gov/rules/index.html
• Bulletins tdi.texas.gov/bulletins/index.html
• eNews tdi.texas.gov/alert/emailnews.html

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Contact TDI

• Consumer Protection Help Line 1-800-252-3439
• Consumer Protection consumerprotection_at_tdi.texas.
  gov
• Rachel Bowden rachel.bowden_at_tdi.texas.gov

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Questions?