MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT RESOURCE GUIDE
MENTAL HEALTH PARITYAND ADDICTION EQUITY ACTRESOURCE GUIDEMay 2014THE UNIVERSITY OF MARYLAND CAREY SCHOOL OF LAWDRUG POLICY AND PUBLIC HEALTH STRATEGIES CLINIC
2PARITY ACT RESOURCE GUIDETABLE OF CONTENTSIntroduction.3Summary of Federal and State Parity Law.3Charts: Plan Type and Applicable Parity Law.5Parity Act Standards and “Red Flags” for Identifying Parity Act Violations. . . . . . . . . . . . . . . 101. Parity Act Standards. . . . . . . . . . . . . . . 112. “Red Flags”. . . . . . . . . . . . . . . 14Disclosure Provisions. . . . . . . . . . . . . . . 16Guidance for Appeals. . . . . . . . . . . . . . 191. Appeals for Private Insurance Claims. . . . . . . . . . . . . . 202. Medicaid Appeals. . . . . . . . . . . . . . 22HOW TO USE THIS RESOURCE GUIDEThis Resource Guide offers providers and consumers essential guidance on the application of the Mental HealthParity and Addiction Equity Act (Parity Act) to public and private health insurance offered in Maryland. The goal is tohelp identify whether insurance companies and entities that administer Medicaid are limiting the scope or duration oftreatment for mental health and substance use disorders (MH/SUD) or requiring patients to pay more for theirMH/SUD care, in violation of the Parity Act. This guide identifies the standards put in place by federal Parity Actregulations issued in November 2013 and Maryland’s state parity law.Darci Smith and Will Dwyer, student-attorneys with the Drug Policy Clinic, prepared this Resource Guide. If youhave any questions, please contact Ellen Weber at the University of Maryland Carey School of Law Drug Policy Clinic:eweber@law.umaryland.edu.
3INTRODUCTION TO THE FEDERAL PARITY ACTThe Mental Health Parity and Addiction Equity Act of 2008 (Parity Act) is intended to end discrimination inhealth insurance coverage for persons with mental health and substance use disorders (MH/SUD). The law requireslarge employers that offer health insurance that includes MH/SUD benefits to provide coverage that is on parwith coverage for medical/surgical (M/S) conditions. The Parity Act does not mandate that a plan provideMH/SUD benefits. But if a large employer’s commercial (fully insured) or self-insured health plan does provideMH/SUD benefits, then it must follow parity standards. In Maryland, all large group commercial plans mustprovide MH/SUD benefits, and they must provide coverage that complies with the Parity Act.Additionally, the Affordable Care Act (ACA) requires all individual and small group health plans sold in thecommercial market after January 2014 to provide MH/SUD benefits and to comply with the Parity Act standards.All individual and small group plans sold on Maryland Health Connection or in the commercial market providecomprehensive MH/SUD benefits.Finally, the Parity Act requires Medicaid managed care organizations that offer MH/SUD benefits to providethose benefits on par with M/S benefits. Under the ACA, Medicaid benefits that are delivered to the newly eligiblepopulation must also cover MH/SUD benefits and must comply with the Parity Act regardless of whether amanaged care organization (MCO) or a non-managed care arrangement, such as an administrative servicesorganization (ASO), delivers the health benefits. In Maryland, substance use disorder benefits, which are currentlyprovided by Medicaid MCOs, must comply with the Parity Act, and mental health benefits, provided through anASO, must also comply under the ACA. Basic Parity Standards. The Parity Act prohibits health plans from providing MH/SUD benefits that are morerestrictive than the M/S benefits they offer, with respect to the following coverage features:o Financial requirements, such as copays, deductibles, and other cost-sharing requirementso Quantitative treatment limitations, such as day limits and visit limitso Non-quantitative treatment limitations, plan design features that limit the scope or duration of treatment,including medical management, medical necessity and authorization standards, provider network standardsand reimbursement rates, and fail-first policies.o Annual and lifetime dollar limits on benefit paymentsClassifications. Benefits for MH/SUD are compared with M/S services within each of six classifications.o Outpatient, in-networko Outpatient, out-of-networko Inpatient, in-networko Inpatient, out-of-networko Emergency careo Prescription drugsParity Standard for Financial Requirements and Quantitative Treatment Limitations. The federal parity lawprohibits applicable health plans from imposing financial requirements (such as co-pays and deductibles) ortreatment limitations (such as visit limits) on MH/SUD benefits that are separate from or more restrictive thanthe predominant requirements or limitations applied to substantially all M/S benefits in the same classification.Parity Standard for Non-quantitative Treatment Limitations. A health plan cannot impose plan managementstandards for MH/SUD benefits that are not comparable to the standards used for M/S benefits and cannot applythose standards more stringently for MH/SUD benefits.Required Disclosures. Plans must make certain information available, free of charge, with regard to MH/SUD
4benefits and adverse decisions.o Medical Necessity Criteria. Criteria for medical necessity determinations with regard to MH/SUDbenefits must be made available to any current or potential participant, beneficiary, or contracting providerupon request.o Denials of Reimbursement or Payment for Services. The reason for any denial of reimbursement orpayment for services with regard to MH/SUD benefits must be made available within a reasonable time tothe participant or beneficiary, upon request or as otherwise required.o Please see page 16 for more information on the required disclosures.MARYLAND’S PARITY LAW Standards. Maryland’s parity law mandates coverage for MH/SUD treatment, including outpatient treatment,partial hospitalization and inpatient treatment.Scope. Maryland’s parity law applies to large group fully insured health plans and individual health policies sold inMaryland. It does not apply to small group health plans. The ACA and Maryland’s benchmark plan now require allindividual and small group health plans sold in the commercial market to offer a wide range of MH/SUD benefits intheir plans and to ensure those benefits are designed in compliance with the federal Parity Act.Effect. In Maryland, large group health plans that are sold on the commercial market must provide MH/SUDtreatment and must comply with the federal Parity Act. Individual policies and small group plans, other than selfinsured small group plans and grandfathered small group plans, must comply with the Parity Act.MEDICAIDIn Maryland, SUD services that are delivered through managed care organizations (MCOs), including MH/SUDbenefits provided to the newly eligible expansion population through an MCO or the administrative servicesorganization (ASO) must comply with the Parity Act. The Centers for Medicare & Medicaid Services (CMS) haveprovided guidance on parity compliance for Medicaid benefits dated Nov. 2009 and Jan. 2013. Specifically, MedicaidMCO plans must:o Ensure that financial requirements (such as deductibles, co-payments, co-insurance, and out-of-pocketexpense limits) applicable to MH/SUD benefits are no more restrictive than the predominant financialrequirements applied to substantially all M/S benefits in the State’s benefit plano Ensure that treatment limitations (both quantitative and non-quantitative) for MH/SUD benefits are nomore restrictive than those imposed on M/S benefitso Provide out-of-network coverage for MH/SUD benefits if M/S benefits may be delivered by out-ofnetwork providerso Provide information regarding criteria for medical necessity determinations and the reason for any denial ofreimbursement or payment for services with respect to MH/SUD benefits.
5PLAN TYPE AND APPLICABLE PARITY LAWPlan TypeApplicable LawRequired Coverage MH/SUD BenefitsIndividualHealth PolicyFederal Parity Act andACA MH/SUD Benefits – Maryland Benchmark PlanParity ComplianceSmall GroupPlanCommercialMarketFederal Parity Act andACA MH/SUD Benefits – Maryland Benchmark PlanParity ComplianceSmall GroupPlanSelf-InsuredNo Parity Law Applies No requirement that plan provide MH/SUD BenefitsNo requirement to comply with Parity if the plan does provideMH/SUD BenefitsLarge GroupPlanCommercialMarketFederal Parity Act andMaryland Parity Law Maryland - MH/SUD BenefitsParity ComplianceLarge GroupPlanSelf-InsuredFederal Parity Act If the plan provides MH/SUD benefits, they must be providedin Parity Medicaid/HealthChoice MH/SUD benefitsParity ComplianceMedicaid –Federal Parity Act throughMCO and ASO ACA and CMS Letters andState Law
6INDIVIDUAL POLICYPlan TypeIndividualHealth PolicyApplicable LawFederal Parity Act andACAIndividualMaryland Parity Law andHealth Plans- Federal Parity ActGrandfathered Md. Code Ann., Ins.§ 15-802Scope of Mental Health and Substance Use Disorder BenefitsRequired Professional Services by Licensed Professionalso Diagnosis and Treatment Diagnostic evaluation; Crisis intervention and stabilization for acuteepisodes; Medication evaluation and management(pharmacotherapy); Treatment and Counseling (including individualor group therapy visits); Diagnosis and treatment of alcoholism and drugabuse, including detoxification, treatment andcounseling; Professional charges for intensive outpatienttreatment in a provider’s office or otherprofessional settingo Electroconvulsive Therapy;o Inpatient professional fees;o Outpatient diagnostic tests provided and billed by alicensed mental health and substance abusepractitioner;o Outpatient diagnostic tests provided and billed by alaboratory, hospital or other covered facility;o Psychological and neuropsychological testingnecessary to determine the appropriate psychiatrictreatment. Outpatient Hospital - services such as partial hospitalization orintensive day treatment programs Inpatient Hospital and Inpatient Residential Treatment Centerso Room and board;o Other facility services and supplies Emergency room - outpatient services and supplies billed by ahospital for emergency room treatment Prescription Drug Benefito Must provide, at a minimum, two medications for bothalcohol and drug dependence Outpatiento Must be covered under the same terms and conditionsthat apply to similar benefits available under the contractfor physical illness Partial Hospitalization - at least 60 days for MH/SUD Inpatiento Same number of days for MH/SUD as M/S
7SMALL GROUP PLANSPlan TypeSmall GroupPlans (50 orfeweremployees)CommercialMarketApplicable LawFederal Parity Actand ACA Small GroupPlanSelf-InsuredSmall GroupPlanCommercialMarketGrandfatheredNo Parity LawAppliesNo Parity LawApplies. State LawCOMAR 31.11.06.03and 31.11.06.05Scope of Mental Health and Substance Use DisorderBenefits RequiredProfessional Services by Licensed Professionalso Diagnosis and Treatment Diagnostic evaluation; Crisis intervention and stabilization foracute episodes; Medication evaluation and management(pharmacotherapy); Treatment and Counseling (includingindividual or group therapy visits); Diagnosis and treatment of alcoholism anddrug abuse, including detoxification,treatment and counseling; Professional charges for intensive outpatienttreatment in a provider’s office or otherprofessional settingo Electroconvulsive Therapy;o Inpatient professional fees;o Outpatient diagnostic tests provided and billed by alicensed mental health and substance abusepractitioner;o Outpatient diagnostic tests provided and billed by alaboratory, hospital or other covered facility;o Psychological and neuropsychological testingnecessary to determine the appropriate psychiatrictreatment.Outpatient Hospital - services such as partialhospitalization or intensive day treatment programsInpatient Hospital and Inpatient Residential TreatmentCenters serviceso Room and board;o Other facility services and supplies.Emergency room - outpatient services and supplies billedby a hospital for emergency room treatmentPrescription Drug Benefito Must provide, at a minimum, two medications forboth alcohol and drug dependence No requirement to provide MH/SUD Benefits Inpatient Hospitalization- 60 Dayso DetoxificationPartial Hospitalization 2 Days for 1 Inpatient dayOutpatient- Cost-sharing: 70% Carrier, 30% Enrollee (innetwork) and 50% Carrier, 50% Enrollee (out-of-network)Services must be accessed through Managed Care System
8LARGE GROUP PLANSPlan TypeApplicable LawScope of Mental Health andSubstance Use Disorder BenefitsRequired Large Group Plan (50 Employees) - Commercial MarketFederal Parity ActMaryland Parity Law Md. Code Ann., Ins. § 15802 Large Group Plan (50 Employees)- Self Insured*Federal Parity Act Outpatient*o Must be covered under thesame terms and conditionsthat apply to similar benefitsavailable under the contractfor physical illnessesPartial Hospitalization - at least 60days for MH/SUDInpatiento Same number of days forMH/SUD as M/SNo mandated scope of servicesIf MH/SUD benefits are provided,they must be in parity with M/SbenefitsMaryland’s large employers that are commercially insured must comply with the Parity Act because they are required to provideMH/SUD benefits under the Maryland parity law. This means that the scope of benefits, required by state law, is the narrowest scope ofbenefits that the large employer can provide. The scope of benefits for MH/SUD benefits must be comparable to the scope of M/Sbenefits. 29 CFR § 2590.712(c)(2)(ii).
9MEDICAID MANAGED CARE ORGANIZATIONSSUBSTANCE USE DISORDER BENEFITSPlan TypeMedicaid - Managed CareOrganization (MCO)Applicable LawFederal Parity Act CMS Guidance Letters(Nov. 2009, Jan. 2013)State LawCOMAR. § 10.09.67.10,10.09.65.04, and 10.09.65.11Scope of Substance Use DisorderBenefitsHealthChoice Benefit: Comprehensive Assessment; Information and Referral Coordination of Care Outpatient Individual andGroup Counseling; Intensive Outpatient services; Opioid Maintenance Treatment; Partial Hospitalization inhospital setting; Residential and InpatientTreatment for Persons Under 21 Medically Managed InpatientDetoxification Case Management forindividuals with HIV, pregnantor postpartum women and otherpersons with SUD Prescription Drugs
10PROVIDER PARITY RESOURCE GUIDEPARITY ACT STANDARDS AND “RED FLAGS”TIPS FOR IDENTIFYING PARITY ACT VIOLATIONS
11PLAN FEATURES REGULATED BY THE PARITY ACTFinancial RequirementsA health plan regulated by the Parity Act that provides MH/SUD benefits may not apply any financialrequirement to those benefits that is more restrictive than the predominant financial requirement of the typethat is applied to substantially all medical/surgical benefits in the same classification. A financial requirementmay not be applied to MH/SUD benefit unless it applies to 2/3 of the M/S benefits. The level of thefinancial requirement applied to MH/SUD benefits can be no greater than the level applied to 51% ofthe M/S benefits. The carrier has the data needed to make these calculations. The financialrequirements most often applied to plans are listed below.FINANCIAL REQUIREMENTSCopaymentThe dollar amount the patient is expected to pay at the time of service.CoinsuranceA percentage of the cost of covered treatment that a patient must pay after thedeductible is met.DeductibleThe dollar amount the patient must pay before the insurer will pay for anyMH/SUD treatment. Plans cannot have a separate deductible for MH/SUDbenefits (e.g., a deductible that applied to MH/SUD benefits, but not M/S benefits)Out-of-PocketMaximumThe total amount a patient is required to pay towards the cost of MH/SUDtreatment.Admission FeeThe dollar amount that the patient is expected to pay at the time of admission forMH/SUD treatment.AggregateLifetime DollarLimitsThe total dollar amount the plan will pay for MH/SUD treatment over the courseof the patient’s life. The ACA prohibits annual and lifetime limits on all essentialhealth benefits, which includes MH/SUD benefits. Individual and small groupcommercial plans, and any plan that provides MH/SUD benefits that satisfies adefinition of essential health benefits that has been approved by the Secretary ofHHS, cannot place annual or lifetime limits on MH/SUD benefits. For example, asmall group, self-insured plan with a benefit approved as an essential health benefit,may not impose an annual or lifetime limit on that benefit.Annual DollarLimitsThe total dollar amount the plan will pay for MH/SUD treatment in a 12-monthperiod.
12Quantitative Treatment LimitationsQuantitative treatment limitations are regulated in the same fashion as financial requirements. A quantitativetreatment limitation may not be applied to MH/SUD benefit unless it applies to 2/3 of the M/Sbenefits. The level of the quantitative treatment limitation applied to MH/SUD benefits can be nogreater than the level applied to 51% of the M/S benefits. The carrier has the data needed to make thesecalculations. The treatment limitations that are most often applied to plans are listed below.TREATMENT LIMITATIONSA numerical limit on the frequency of MH/SUD treatment that the patient may receive.Limits onFrequency ofTreatmentLimits on Numberof VisitsA limit on the number of visits for MH/SUD treatment allowed under the patient’s plan,usually for outpatient treatment.Limits on Numberof DaysA limit on the number of days for MH/SUD treatment or service allowed under the patient’splan, usually for inpatient treatment.Length of Stay PerEpisodeA limit on the length of MH/SUD treatment or service allowed per episode.
13Nonquantitative treatment limitationsNonquantitative treatment limitations include medical management standards and all plan features that maylimit the scope or duration of benefits. The Parity Act requires that the standards used to impose theselimitations on MH/SUD benefits be comparable to the standards used for M/S benefits. For example, a planmust use comparable criteria for MH/SUD and M/S benefits in determining whether prior authorization isapplied to MH/SUD and M/S benefits. Additionally, these standards cannot be applied more stringently toMH/SUD benefits than to M/S benefits. An illustrative list of nonquantitative treatment limitations isprovided below.ExclusionsAuthorizationNON-QUANTITATIVE TREATMENT LIMITATIONSBased on failure to complete treatment. Pre-Authorization: the insurer reviews care before treatment begins for medical necessity.Concurrent Authorization: the insurer reviews care periodically to assess continued medicalnecessity.Retrospective Authorization: the insurer reviews care after the treatment has beenperformed for medical necessity.MedicalNecessityCriteriaCriteria used by health insurance plan to determine whether treatment or services are “medicallynecessary” before providing reimbursement or coverage. Includes “medical appropriateness” standards: whether the treatment is deemedexperimental or investigative“Fail First”PoliciesThe patient must fail using one medication or in one level of treatment before another isapproved.Step TherapyProtocolsThe patient must first try the least expensive care before being allowed to try the next leastexpensive care.ProviderIncluding reimbursement rates and provider network criteria.Admission toCarrier NetworksServiceReimbursementPlan methods for determining usual, customary, and reasonable charges.Plan standardsthat limit thescope orduration ofbenefitsRestrictions based on geographic location (such as services accessed outside of the state), facilitytype (whether services are accessed in a hospital or residential treatment center), providerspecialty (such as an exclusion for services provided by a clinical social worker), and othercriteria that limit the scope or duration of benefits for services provided.PrescriptionDrugsFormulary design.Netwo
This Resource Guide offers providers and consumers essential guidance on the application of the Mental Health . benefits provided to the newly eligible expansion population through an MCO or the administrative services organization (ASO) must comply with the Parity Act. . Professional Services by Licensed Professionals o Diagnosis and Treatment
7 Application of the Parity Act The Parity Act only applies to health plans that provide mental health and substance use disorder benefits. Substance Abuse and Mental Health Services Administration, Parity of Mental Health and Subst ance Use Benefits with Other Benefits: Using Your Employer-Sponsored H ealth Plan to Cover Services, HHS Publication No. SMA-16-4937, Rockville, MD: Substance Abuse
upon. Each traditional NetApp RAID 4 group has some number of data disks and one parity disk, with aggregates and volumes containing one or more RAID 4 groups. Whereas the parity disk in a RAID 4 volume stores row parity across the disks in a RAID 4 group, the additional RAID-DP parity disk stores diagonal parity across the disks in a RAID-DP .
final report preparing for the futurethe mental health & of artificial intelligencesubstance use disorder parity task force - p “to realize the promise of coverage expansions and parity protections in helping individuals with mental health and substance use disorders, executive departments and agencies need to work together to ensure that americans are benefiting from the federal parity .
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) supplemented the Mental Health Parity Act of . 1996 (MHPA), which ensured that annual and lifetime dollar limits on mental health benefits were no more restrictive than those imposed on medical/surgical (also known as physical health) benefits. Generally, MHPAEA requires that the
Addiction & Mental Health Terminology Guide 1 The Purpose of this Guide People and media have used different terms over the years when referring to addiction and mental health issues. Sometimes it’s been helpful, such as describing mental illness and addiction using “people first” terms (e.g, a person living with a mental illness).
services, preventive health services, and emergency health care services, including ambulance services.16 1999 Following enactment of the federal Mental Health Parity Act of 1996, California passed the California Mental Health Parity Act,17 requiring all health care plans regulated by the California Department of Managed Health Care (DMHC) and all
disorder-parity . Parity of Mental Health and Substance Use Benefits with Other Benefits: Using Your Employer- Sponsored Health Plan to Cover Services - Guide protections, gives examples of ways in which parity applies to mental health and substance use disorder benefits, and includes information about how to appeal a claim that has been .
The K-map simplification for 3-bit message even parity generator is From the above truth table, the simplified expression of the parity bit can be written as The above expression can be implemented by using two Ex-OR gates. The logic diagram of even parity generator with two Ex - OR gates is shown below. The three bit message along
