The Massachusetts and Federal
Mental Health and Addiction Parity Laws:
Summary and Recent Policy Developments
Children’s Mental Health Campaign
Supporter’s Meeting
January 29, 2013
Health Law Advocates
Jenifer Bosco, Staff Attorney
1
What is parity?
In general, parity laws say that health
insurance companies must cover mental
health and substance use disorder (SUD)
treatment in the same way that they cover
treatment for physical health conditions.
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Know Your Plan, Know Your Rights
• Different parity laws apply, depending on
what kind of health plan you have
• “Fully insured” plans
• “Self insured” or “self funded” plans
• State and municipal employee plans
3
Who is covered by the
Massachusetts Parity Law?
• State parity law applies to:
• All fully-insured group health plans
• Non-group health plans
• Fully-insured health plans delivered in Massachusetts or outside of
Massachusetts
• GIC (state government employee plans)
• Does not apply to:
•
•
•
•
•
•
Self-insured health plans
Incarcerated persons, including youth in DYS custodial facilities
Medicare
MassHealth
Veteran’s insurance through TRICARE
Federal government employees
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Who is covered by the
Federal Parity Law?
•
Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 (MHPAEA)
•
MHPAEA applies to:
• Self-insured AND fully-insured group health plans of
employers with more than 50 employees (i.e. large group
health plans)
• Large group health plans that offer mental health or
substance abuse benefits
• State and local government employers
• MassHealth managed care plans
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Who is not covered by the
Federal Parity Law?
MHPAEA does not apply to:
• Employers with 50 or fewer employees (note: this may
change in 2014)
• Federal government employees, or non-federal
government employers that opt out
• TRICARE
• Medicare
• Large group health plans that receive actuarial certification
that compliance will increase claims by 2 percent
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Types of plans/Parity laws
Type of Health Plan
Does Mass. Parity Law
apply?
Does Federal Parity Law
(MHPAEA) apply?
Self-insured with
more than 50 employees
No
Yes
Self-insured with
50 or fewer employees
No
No
GIC (State employees)
Yes
Yes
Fully-insured with
more than 50 employees
Yes
Yes
Fully-insured with
50 or fewer employees
Yes
No (may apply in 2014)
Individual
Yes
Maybe (will apply in 2014)
MassHealth
No
Yes (except fee-for-service)
Medicare
No
No
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Massachusetts Parity Law
• Applies only in Massachusetts
• Requires non-discriminatory coverage for diagnosis and
treatment of certain biologically based conditions in adults
• Non-Discriminatory: Annual or lifetime dollar or unit of service
limitations on coverage for the diagnosis and treatment of certain
biologically based mental illnesses may not be less than any such
limitation imposed on coverage for diagnosis and treatment of physical
conditions
• Under the Affordable Care Act (“Obamacare”), no more lifetime limits
and no unreasonable annual limits beginning in 2014
• Copayments, coinsurance and deductibles cannot be greater for mental
disorders than for physical conditions.
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Biologically Based Mental Illnesses That Must
Have Non-Discriminatory Coverage
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Schizophrenia
Schizoaffective disorder
Major depressive disorder
Bipolar disorder
Paranoia and other psychotic
disorders
Obsessive-compulsive disorder
Panic Disorder
Delirium and dementia
Affective disorder
•
•
•
•
Eating Disorders*
PTSD*
Substance Abuse Disorders*
Autism*
• Also, Rape-related mental or
emotional disorders to victims
* Added in 2008
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What about conditions
that are not on the list?
• Minimum = 60 days of inpatient treatment
and 24 outpatient visits per year for the
diagnosis and treatment of all other mental
disorders described in the most recent edition
of the DSM
• Federal laws may require additional visits and
inpatient treatment days
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What types of care?
• Requires that a full scope of services must be
covered: inpatient, outpatient and
intermediate care
• Intermediate care includes residential
programs, in-home therapy, partial
hospitalization, etc.
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Children and Adolescents
• Mandates non-discriminatory coverage for
children and adolescents for diagnosis and
treatment for additional disorders
• Additional disorders: Conditions listed in the
most recent DSM that substantially interfere
with or substantially limit child’s functioning
and social interactions
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Federal Parity Law: the Mental Health
Parity and Addiction Equity Act
•
No “mandated benefit”
•
Non-discriminatory financial requirements in coverage for
mental health and substance use disorder care
•
Non-discriminatory treatment limitations in coverage for
mental health and substance use disorder care
•
Availability of certain information on health plan coverage
determinations
•
Non-discriminatory access to out-of-network providers
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What are “nonquantitative treatment
limitations”?
Under the federal parity law, it is illegal for health plans
to discriminate in:
• Medical management standards (e.g., techniques for
managing care such as prior authorization, concurrent
review and utilization review policies)
• Standards for provider admission to join a network,
including reimbursement rates
• Formulary design for prescription drugs
• Fail-first policies
• Exclusions based on failure to complete a course of
treatment
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Example
Kim had to go to the hospital to have her
appendix removed, and her health plan covered
her three-day hospital stay. Four months later,
Kim sought inpatient hospitalization for her
bipolar disorder. The health plan first required
“prior authorization,” and then approved only
one day in the hospital. Does this violate the
state parity law? The federal parity law?
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Availability of information on health plan
coverage determinations
Medical Necessity: Health plans are still allowed to
decide if care is medically necessary
Criteria: Health plans must make available the criteria
used for medical necessity determinations for mental
health or substance use disorder benefits
Reason for denial: Health plans must provide enrollees
with the reason for any denial of coverage for mental
health or substance use disorder care
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Etc…
More UBH “Level of Care” Guidelines at:
https://www.ubhonline.com/html/guidelin
es/levelOfCareGuidelines/
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Next Steps after a denial:
• Internal Review
• External Review
• Office of Patient Protection
• Self-Insured plans
• ERISA litigation
• State and Federal agency enforcement
• U.S. Department of Labor, Employee Benefit Security
Administration
• U.S. Health and Human Services Department
• Massachusetts Division of Insurance
22
External Review, general practices
• Review written denial from health plan,
criteria, and the supporting evidence
• Obtain a copy of the file from the health plan
• Point out any evidence that was ignored, or
where the decision was contrary to the
evidence on file
• Submit any additional supporting documents
or letters from providers
23
Recent Massachusetts policy
developments
• 2012 Payment Reform Law (Ch. 224, Sections
23, 254, 265, 275) gives DOI the authority to
enforce the federal parity law for some plans
• New annual reporting requirements
• DOI and MassHealth directed to create parity
regulations
• Behavioral Health Task Force created
• Creation of HPC, which will now operate OPP
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Recent federal policy
developments
Medicaid
• January 16 CMS State Director letter
• Medicaid managed care plans must comply
with parity, including non-quantitative
treatment limitations
Private Insurance
• Administration says final MHPAEA regulations
will be released soon, possibly spring of 2013
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Resources:
Government Enforcement
• United States Department of Labor, Employee
Benefits Security Administration at 1-866-444-3272
or www.askebsa.dol.gov
• United States Department of Health and Human
Services at 1-877-267-2323 extension 6-1565 or at
phig@cms.hhs.gov
• Office for Patient Protection at 1-800-436-7757
• Massachusetts Division of Insurance at 888-283-3757
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More information:
• Parity laws and other resources posted at
http://www.healthlawadvocates.org
http://marylandparity.org/
http://www.dol.gov/ebsa/mentalhealthparity/
• Mental Health/Substance Use Treatment Toolkit and
other information at parityispersonal.org
• Health Law Advocates: 617-338-5241
• Health Care For All: 800-272-4232
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