Federal Mental Health
Parity:
What You Need to Know
Small Business 2-99
Discussion Topics
•What is Federal Mental Health Parity Addiction & Equity Act (FMHPAEA)
•Federal Legislation 101 & UHC’s approach
•What is happening for impacted groups
• The ‘employs 50’ rule
• General guidelines
•Documentation
• Contracts
• Benefit Summaries,
• Addendum Tool
•Sales Involvement
•Case Installation Requirements
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What is Mental Health Parity?
In late 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act (MHPAEA) was signed into law. This law updated the
existing mental health parity laws by now applying them to both Mental
Health and Substance Use Disorder benefits (MH/SUD). The Interim Final
Rule was published February 2, 2010, implementing the MHPAEA (the
“Rule”).
This new Rule requires that the treatment limitations applied to mental
health and substance use disorder benefits be no more restrictive than
those applied to a customer’s medical/surgical benefits.
It is now a requirement that one deductible and out of pocket maximum limit
cover all medical and MH/SUD services. It is no longer allowed to have
separate but equal deductibles and out of pocket limits applying to the
medical and the MH/SUD services.
The Rule affects all groups that employ 51 or more people. The Rule goes
into effect with all new and renewing customers groups as of 7/1/2010.
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High Level Overview
Federal Mental Health Parity Addiction Equity Act applies to new and renewing
customers as of July 1, 2010, that EMPLOY more than 50 persons: this count includes
part time and seasonal employees for purposes of this Federal legislation.
General Provisions—Benefit Plans:
• Must have shared deductibles between medical and behavioral. It is no longer permissible
to have separate but equal deductibles.
• Must have shared out of pocket maximums between medical and behavioral. It is no longer
permissible to have separate but equal out of pocket maximums.
• Must remove any day limits under inpatient behavioral services unless there are the same
limits applied to the medical/surgical inpatient hospital stay.
• Must remove any visit limits under outpatient behavioral services unless there are the same
limits applied to the medical/surgical benefits – Physician Office Services/Sickness and
Injury
• Must apply same non-quantitative treatment limitations to behavioral services as that are
applied to medical/surgical benefits. This includes prior authorization, medical
management. any penalty for lack of following prior authorization requirements, etc.
• Must apply the 2/3rd rule for medical/surgical costs before the behavioral health cost share
can be determined. This step has been completed by Actuary for SB plans and is included
in the addendums.
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General Guidelines on plan design changes
•The “Substantially All” - 2/3’s rule: “tests” each financial requirement (e.g.,
copay, deductible, coinsurance) to see whether that requirement applies to
“substantially all” medical/surgical benefits (2/3 or more) within the specific
classification of benefits: Inpatient INN, Outpatient INN, Inpatient OON,
Outpatient OON, and ER. (The “substantially all” test for Prescription Drug is
one of reasonability. See next slide for details.)
• If a type of financial requirement or treatment limitation does not apply to
“substantially all” medical/surgical benefits in that classification, it cannot
be applied to Mental Health or Substance Use Disorder.
• 2007/09: If plan has OV copay and cost sharing for all other office based services, then
outpatient MH/SU services will be 100% - no ded, no copay. Does not pass 2/3 rule.
• 2007/09: If plan is ded/coins – then outpatient MH/SUD services will remain at
ded/coins. Passes 2/3 rule.
• 2001/02: If plan has OV copay and outpatient Surgery copay – then MH/SUD services will
remain at Specialist copay. Passes 2/3 rule
• 2001/02: If plan has a OV copay (no outpatient Surgery copay) – then MH/SUD services
will be no cost share. Does not pass the 2/3 rule.
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Federal Rules on Group Size—SB Change
For purposes of Federal Mental Health Parity, groups with over 50 TOTAL employees
need to comply with the legislation
•TOTAL employee count includes:
• Full time,
• Part time,
• Seasonal/temporary employees
• Employees in the waiting period.
Does not include 1099 employees
•Letter to Brokers is being sent to advise them of this change and to let them know
employer letters are being sent.
•Employer Letters are being sent to 2-50 size groups starting with July, 2010 renewals
• Letters will be sent directly for July, August and some September renewals. Goal will be to include
the letter in the renewal package going forward.
• Letters are being sent across all platforms
Special communication with both letters and an FAQ is being sent to all SB Sales Staff
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New Business
For New Groups effective 7-01-2010
• If a group has more than 50 total employees, the
appropriate benefits consistent with their plan design will
be added to the group—no plan code change, no rate
change. Benefit cost will be included in medical trend
going forward.
• The Employer Group Application and the New Business
Cover Sheet will used by Case Install using TOTAL number
of employees to assure compliance.
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Renewals
For SB Renewals July, August and September letters will be
sent to 2-50 employers asking for verification of total
employees.
• The letters are going out for all platforms and will each contain unique
fax number and contact information
Beginning in September for Prime based business renewals,
the letter will be included in the renewal package.
For groups that have more than 50 TOTAL employees, the
appropriate mental health benefits will be added to their
benefit plan—no plan code change, no rate change but the
additional benefits will be included in medical trend going
forward.
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Fully Insured Impact – Groups 2-99
•FMHP DOES apply if the group employs more than 50.
• We will be reaching out to Brokers and employers via a letter asking them to acknowledge if they meet the federal
definition of a large group for purposes of mental health benefits.
•Since most current 2-50 groups will not be subject to this Act, there will be no change in overall
benefit plan design, codes or names. The mental health/substance use benefits will be updated
within current plans through a rider as follows:
•The mental health/substance use benefits will be updated as follows:
• Day limits will be removed, if required
• Visit limits will be removed, if required
• Prior authorization penalty will change to 50% of eligible expenses to match that of medical to support the
nonquantitative treatment limitation requirement
• In many instances the member’s Network outpatient mental health/substance use copay will change to have no cost
share to meet the 2/3rd requirement <see slide 5 for definition of 2/3rd rule>
• Continue to have shared deductibles between medical/surgical and mental health
• Continue to have shared out of pocket maximums between medical/surgical and mental health
•If the customer meets this ‘employs more than 50’ criteria and the GA/Broker adds the group
online via UeS, there will be two new optional riders they will need to select in order for the
federally qualified employer group to get the appropriate behavioral benefits.
• UeS has been updated with two new medical optional riders. Those optional riders are Mental Health Parity 2 and
Mental Health Parity 2 TEO50 (total employees over 50). These 2 options are for the revised Mental Parity effective
7/1/10 to identify groups with less than 51 eligible employees but more than 50 total employees. If that is the case, both
options should be selected. If not, neither option should be selected.
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UeS Screenshot for Mental Health Riders
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What’s happening behind the scenes for all
impacted groups?
Phase 1 – already completed (10/3/09)
•No change in benefit plan design CODES or NAMES for UNET
•Created benefit summary addendums for the impacted plan designs or updated
state specific benefit summaries
•Removal of day and visit limits for groups 51+
•Federal Notice was updated to incorporate new requirements
•Phase 2- happening NOW and will be completed by 7/1/2010
•Creating benefit summary addendums for the impacted plan designs
•For 51+ plan designs, removing mental health limits to achieve compliance, for
groups ‘employing 50’ adding a rider to remove mental health limits (claims
perspective only)
•Changing mental health benefits to be parity compliant within in our claims
systems
• Federal Notice will be updated to incorporate new requirements
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Federal Definition of a Small Group Mailings
National SB Sales Leadership call—May 21
Letters to Brokers –May 27
Letter to Employers—first phase (July and August renewals)
direct letter for groups 20+ May 28, 2010
Letter to Employers included in all 2-50 renewal packages
September, 2010 to June 2011)
Mental Health Parity changes for new business and renewals
effective 7-2010
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Addendum Tool for Benefit Summary Information
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Introduction
The Federal Legislation Benefit Summary Addendum Website was developed
to locate the correct Federal Legislation Benefit Summary Addendum for the
user based on the current status of the states Benefit Summaries. This
website addendum’s support both Pre-2007 and 2007 COC Series.
•
Not all Benefit Summaries have been revised to include the October 2009 and July 2010
Federal Legislation benefit and language changes.
•
To support the October 2009 and/or July 2010 Federal Legislation benefit and language
changes, over 40 Benefit Summary Addendum’s have been created.
The user will enter some basic information regarding the plan design that was
sold into the website page and the correct Federal Legislation Benefit
Summary Addendum and Print Care Code will be displayed.
If the Benefit Summary includes the October 2009 and July 2010 Federal
Legislation benefit and language changes, a message that an Addendum is not
required will display on the website.
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The Addendum Tool
Addendum Tool: http://webe0065/FLA/
Tool can be accessed 2 ways:
On Demand Template Website
PAG Fed Leg website
User Guide available on website
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Website Instructions
To search for a Benefit Summary Addendum, go to the Federal Legislation Benefit Summary Addendum
website located at the following address:
http://webe0065/FLA/
The following page will display:
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Website Instructions
Using the drop down box, select the correct Funding Arrangement.
Since we have different Addendums for Self Funded vs Fully Insured, this allows us to provide a copy of the
correct Addendum.
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Website Instructions – Fully Insured
Using the Drop Down box, select whether the plan design sold is from the 2007 COC Series or Pre2007 (which would include COC series between 2001–2005)
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COC Series 2007 Website Instructions – Fully Insured
If the COC Series of 2007 was selected the following screen and questions will display. By answering
all of the questions on this page, the correct Federal Legislation Benefit Summary Addendum will
display.
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COC Series 2007 Website Instructions – Fully Insured
The Print Care Code and Addendum PDF file will display on the
bottom of the page.
To view and/or print the addendum press:
View Addendum
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COC Series Pre-2007 Website Instructions – Fully
Insured
If the COC Series of Pre-2007 was selected the following screen and questions will display. By
answering all of the questions on this page, the correct Federal Legislation Benefit Summary
Addendum would display for the Pre-2007 Plan Design/Benefit Summary.
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COC Series Pre-2007 Website Instructions – Fully
Insured
The Print Care Code and Addendum PDF file will display on the bottom of the page.
To view and/or print the addendum press:
View Addendum
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Addendum Naming Convention
Fully Insured Addendum Naming Convention
1st field =
Funding Arrangement
FI = Fully Insured
2nd field =
Addendum Version
B = Ben Sum's have not been revised with Oct 2009 or July 2010 language.
C = Ben Sum's have been revised with Oct 2009, but not July 2010 language.
3rd field =
Business Segment
KA = Key Account.
SB = Small Business
4th field =
Type of Product
NET = Network only benefits (Choice & Select products)
PLUS = Network and Non-Network Benefits (Choice Plus, Select Plus, Options PPO and NonDiff PPO products)
5th field =
OP MH Benefit
Indicates what type of Outpatient MH benefits the Addendum supports
6th field =
IP MH Benefit
Indicates what type of Inpatient MH benefits the Addendum supports
Definitions for OP and IP fields:
100% = Paid at 100%, no Deduct
DEDCOINS = Paid at Coinsurance and Deductible
Self-Funded Addendum
COPAY =Naming
Paid atConvention
IP Hospital Copayment or Physician Office Service Copayment
1st field =
Funding Arrangement
ASO = Self Funded
2nd field =
Type of Product
NET = supports Choice product. PLUS = supports Choice Plus product
3rd field =
Business Segment
Fed-Leg_Ben_Sum_Addendum
4th field =
Type of Product
PPO = supports Options PPO product
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Addendum Inventory and Naming
Over 40 Addendums have been created to support the different Funding Arrangements, Business Segments,
COC Series, Product Types and Plan Designs:
•
One set of addendums were created for when a states benefit summaries have not been
revised with the Federal Legislation October 2009 language or July 2010 language – these
are called Addendum B.
•
A different set of addendums were created for when a states benefit summaries have been
revised with the Federal Legislation October 2009, but not the July 2010 language – these
are called Addendum C.
•
If the Benefit Summaries have been updated with the Federal Legislation October 2009 and
July 2010 language, a message will display indicating that an Addendum is not needed.
Addendum Naming Convention Small Business
FI_C_SB_PLUS_DEDCOINS_DEDCOINS
This naming convention represents a Fully Insured, Small Business, Network/Non-Network Benefit Summary
Addendum that pays the OP MH and IP MH benefits at the plans Coinsurance and Deductible.
This Addendum supports a states benefit summary that has been revised with the Federal Legislation
October 2009 language, but not the July 2010 language.
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Addendum Example: Page 1 of 2
FI_C_SB_PLUS_DEDCOINS_COPAY
FI_C_SB_PLUS_DEDCOIN
S_COPAY
This Addendum supports:
Benefit Summaries that
have been revised with
the Federal Legislation
October 2009, but not the
July 2010 benefit and
language changes.
Small Business
Network/Non-Network
plans.
Outpatient MH benefits
are paid at the
coinsurance and
deductible.
Inpatient MH benefits that
are paid using the
Hospital Inpatient Stay
Copayment.
PAGE 1 OF THE
ADDENDUM
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Addendum Example: Page 2 of 2
FI_C_SB_PLUS_DEDCOINS_COPAY
FI_C_SB_PLUS_DEDCOIN
S_COPAY
This Addendum supports:
Benefit Summaries that
have been revised with
the Federal Legislation
October 2009, but not the
July 2010 benefit and
language changes.
Small Business
Network/Non-Network
plans.
Outpatient MH benefits
are paid at the
coinsurance and
deductible.
Inpatient MH benefits that
are paid using the
Hospital Inpatient Stay
Copayment.
PAGE 2 OF THE
ADDENDUM
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Addendum Example:
FI_B_SB_NET_100%_DEDCOINS
FI_B_SB_NET_100%_DED
COINS
This Addendum supports:
Benefit Summaries that
have been not been revised
with the Federal
Legislation October 2009
or July 2010 benefit and
language changes.
Small Business Network
only plans.
Outpatient MH benefits are
paid at 100%, deductible
does not apply.
Inpatient MH benefits that
are paid at the coinsurance
and deductible.
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Sales – What do I need to do?
Nothing different
All of the changes will be happening behind the scenes.
Plan Designs
Actuary and Product has reviewed the standard plan designs and have made the required
changes to make sure they are compliant.
Existing SB (51+) cases on PRIME will receive compliant benefits upon renewal.
Use addendum tool if client would like to see the compliant benefit detail at the Federal level.
For cases that have already confirmed renewal or new business sold for 7/1, we will go back
and update benefits to be compliant. Date TBD as to when this will occur.
Be aware of the following:
Brokers and employer groups will be receiving a letter asking them to acknowledge group size
if they employ more than 50 persons.
If a customer in the 2-50 size group meets the federal definition of a large group, their mental
health benefits will be modified to comply with the federal mental health parity
requirements.
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Contracts- What the Customer will receive
Contract Issuance:
•
To update the existing COC’s with necessary contract changes to comply with the enacted Federal Legislation,
every state will be re-filed. The filing will follow the typical approval process. The amendment that will support the
Federal Mental Health changes will be available only after state approval is received and system coding is
completed.
•
If customer has opted in to eCOC the document will be available on myuhc.com
•
While securing state approval of the contract language, it is the expectation that benefits are quoted and
administered according to both federal and state legislation.
•
New customers receive COCs that are on file at the time of their effective date. COCs will not be
retroactively issued.
Notification:
All new and renewing customers will receive the most recent Federal Notice.
•
This notice will describe at a high level the requirements and Benefits for Mental Health Parity. The Federal
Notice is not a filed form, rather than an addition to the COC. The Federal Notice summarizes benefit
requirements and will be used in the interim for all impacted customers while UnitedHealthcare updates its
current COCs. The revised Federal Notice will be in production with all new and renewing groups as of July 1 st. .
•
Federal Notice will be sent via our standard contract delivery process.
No external communication is scheduled at this time to explain the change in the customers benefits
but rather the benefit summaries and supporting addendums should be provided to the group.
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SB Checklist for Mental Health Parity
P
Letter to SB employers on the new Federal definition of
a large group for all July/August and some September
renewals across all platforms:
•Brokers—May 27th
•Employers—May 28th-June 1
P
Standard letter included in UHC renewal package for 901-2010 renewals until 6-01-2011
P
For Groups that are 51+, new benefits will be added to
be compliant for renewals and new business effective
7-01-2010 (no rate change or plan code change---new
benefits will be included in overall trend)
P
P
Addendum tool available to Sales Staff to show the
changes in an employer’s benefits by state and plan
code—some plans will not be affected
New business will use the total number of employees
from the group application to determine if Federal
Mental Health Parity benefits apply.
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Have Questions?
1. For Parity rules & UHC’s interpretation see Connect:
•
Federal Mental Health Parity Interim Regulations (updated March 19, 2010) with the
following attachments:
•
The Mental Health Parity and Addiction Equity Act of 2008 (updated March 11, 2010)
•
SB Connect Communication with FAQ—May 21, 2010
2. Field Contacts for Small Business--RDOs
Karen Finnerty—National
Sharon Carter—West Region
Christy Wooten—Central Region
Pam Williams—SE Region
Lorraine Butzke—NE/Mid-Atlantic Region
3. Regional Product contacts:
Tracy Plunkett – West Region
Rich Nelson – Central Region
Tracey Durham – SE Region
Cathy Lang – NE/Mid- Atlantic Region
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