Mental Health Parity

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that required health plans that offer mental health and/or substance use benefits to do so without imposing copayments, benefit limitations, and other restrictions that are more stringent than those imposed on medical/surgical benefits.

Although the 2008 parity law applies only to large-group insurance plans (for employers with 50 or more employees) and Medicaid managed care, the Affordable Care Act extended parity protections to the small-group and individual market, Medicaid expansion plans, and plans sold through states’ health insurance marketplaces. The ACA also instructed most insurance plans to cover mental health and addiction treatment services, which had not previously been required. Between parity and the ACA, now nearly all health plans must cover behavioral health services at parity with medical/surgical – a huge leap forward for a field that has all too often been poorly covered or left out of coverage entirely.

Final MHPAEA regulations outlining parity requirements for employer-sponsored plans were issued November 2013.  The final regulations reinforce the standards set forth in the interim rule. They prohibit insurers from imposing co-payments, coinsurance, or other financial requirements on mental health and substance use services that are more restrictive than those imposed on medical/surgical services.  This basic parity test applies to “quantitative” benefit limitations – such as outpatient visit caps – as well as “non-quantitative” limitations like formulary design, medical necessity criteria, and prior authorization requirements.

A fact sheet on the rules is available here: http://cms.hhs.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html.

 

Updates:

April 29, 2016: The Centers for Medicare and Medicaid Services (CMS) published final regulations outlining how the 2008 Mental Health Parity and Addiction Equity Act applies to state Medicaid and Children’s Health Insurance programs. This final rule extends parity to more than 23 million Americans covered by these important programs.

Key provisions of the final rule include:

  • Parity Applies to Both Carve-In and Carve-Out – CMS maintained the proposed language of ensuring parity applies to Medicaid managed care beneficiaries even in states where behavioral health services have been carved out of managed care contracts. In such cases, states are responsible for ensuring that the entire package of Medicaid services for managed care enrollees complies with the parity law, regardless of whether the services are delivered in a managed care organization, fee-for-service Medicaid or other delivery arrangement.
  • Plans Must Meet Disclosure Requirements – CMS finalized its proposal requiring Medicaid managed care plans, alternative benefit plans and CHIP plans to make their criteria for medical necessity determinations available to enrollees or contracting providers upon request. Plans must also make available to enrollees the reason for any denial of services. Additionally, states must publicly post documentation of their compliance with the parity requirements outlined in the rule.
  • States, Managed Care Entities Share Responsibility for Compliance – In states where all services are fully included within managed care contracts, managed care organizations are now responsible for ensuring their compliance with parity, even if doing so means covering services beyond the scope of those outlined in the state Medicaid plan. Managed care organizations may include the cost of these services in their calculations of actuarial soundness when contracting with Medicaid, meaning that any additional cost of covering services needed to comply with parity falls squarely on the state.
  • Effective Date – States will have up to 18 months to comply with the finalized provisions.

July 9 2015: The NYS Attorney General’s office has developed two flyers on Mental Health Parity.

April 28, 2015The Legal Action Center developed a summary of the Mental Health Parity proposed rule and has several resources available on their web site.

April 6, 2015:  The federal Centers for Medicare & Medicaid Services (CMS) released a proposed rule that applies the provisions of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) to Medicaid managed care organizations (MCO), Medicaid alternative benefit plans, and Children’s Health Insurance Program (CHIP) plans.   Public comments are due on this proposed rule by June 9, 2015.  For more information, or to review the proposed rule, go towww.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/mental-health-services.html.

 

Parity Appeals Center - August 11, 2014

Please find here the Parity Appeals Center Overview - a description of a recently-launched PIC-initiative, the Parity Appeals Center.  This project is being launched in conjunction with Psych-Appeal, a California based law firm.

As the attached indicates, 10 appeals will be undertaken by the Parity Appeals Center/Psych-Appeal on behalf of PIC consumer and provider organizations.  These appeals will be focused on the most common MHPAEA compliance issues faced by PIC members.

Members should forward cases for consideration to “PAC@parityispersonal.org” with “Parity Appeals Center” in the subject line.  This information is also available in a members-only section of the parityispersonal.org website.  The user name to access the site is “pac” and the password is “parity”.

 

Articles of Interest

On Tuesday, the Centers for Medicare and Medicaid Services (CMS) published final regulations outlining how the 2008 Mental Health Parity and Addiction Equity Act applies to state Medicaid and Children’s Health Insurance programs. This final rule extends parity to more than 23 million Americans covered by these important programs.

CMS reiterated that the broader goal of this long-awaited final rule was to create consistency between public and private health insurance markets, as well as parity between mental and physical health treatment services. As outlined in our initial write-up for the proposed rule, the regulation preserves the general parity rule that prohibits health plans from applying financial requirements or treatment limitations to mental health and substance use disorder benefits that are more restrictive than those imposed on substantially all medical/surgical benefits of a similar kind.

Key provisions of the final rule include:

·         Parity Applies to Both Carve-In and Carve-Out
Arrangements
– Thanks in part to the hundreds of comments submitted by National Council members, CMS maintained the proposed language of ensuring parity applies to Medicaid managed care beneficiaries even in states where behavioral health services have been carved out of managed care contracts. In such cases, states are responsible for ensuring that the entire package of Medicaid services for managed care enrollees complies with the parity law, regardless of whether the services are delivered in a managed care organization, fee-for-service Medicaid or other delivery arrangement.

·         Plans Must Meet Disclosure Requirements – CMS finalized its proposal requiring Medicaid managed care plans, alternative benefit plans and CHIP plans to make their criteria for medical necessity determinations available to enrollees or contracting providers upon request. Plans must also make available to enrollees the reason for any denial of services. Additionally, states must publicly post documentation of their compliance with the parity requirements outlined in the rule.

·         States, Managed Care Entities Share Responsibility for Compliance – In states where all services are fully included within managed care contracts, managed care organizations are now responsible for ensuring their compliance with parity, even if doing so means covering services beyond the scope of those outlined in the state Medicaid plan. Managed care organizations may include the cost of these services in their calculations of actuarial soundness when contracting with Medicaid, meaning that any additional cost of covering services needed to comply with parity falls squarely on the state.

·         Effective Date – States will have up to 18 months to comply with the finalized provisions.

The National Council thanks the hundreds of advocates that submitted comments on this proposed regulation. We will continue to review the text of the final rule and will keep readers updated with our latest analyses on Capitol Connector. 

For more information on the final rule, click here