Mental Health Parity &
Addiction Equity
Community Forum
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Presenters
Katharine Ligon, M.S.W.
Policy Analyst, Center for Public Policy Priorities
Rachel Bowden, MPAff, PMP
Program Specialist VI, Texas Department of Insurance
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
• Q&A
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.
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
Timeline of Mental Health Parity
in the United States
Deinstitutionalization
begins, creating a modest
incentive for private
insurers to cover services
not paid for by the public
sector.
1950s
The Federal Employees Health
Benefits Program allows
participating plans to reduce
their mental health benefits.
1960s
President Kennedy urged the
Federal Employees Health
Benefits Program to cover
psychiatric illnesses
comparably to medical
conditions.
1970s
Senators Domenici and
Wellstone elevated mental
health parity on the public
agenda; consumer advocates
characterized lack of parity as
discrimination.
1980s
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.
1990s
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
Timeline of Mental Health Parity
in the United States (cont‘d)
President Bush stated
support for mental
health parity
Mental Health Parity
Act (MHPA) passes
1996
1999
At the first White House
Conference on Mental
Health, President Clinton
announced mental health
and substance use parity
in Federal Employees
Health Benefits Plan
2002
Mental Health Parity
and Addiction Equity
Act (MHPAEA) passes
2003
The New Freedom
Commission on
Mental Health’s 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.
2008
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
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
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
Federal Mental Health Parity
MHPAEA: Implementation
Classification of Benefits:
• Inpatient / In-network
• Inpatient / Out-of-network
• Outpatient / In-network
• Outpatient / Out-of-network
• Emergency Care
• Prescription Drugs
Cumulative Financial Requirements: deductibles and out-ofpocket limits must combine both medical and MH/SU benefits
Quantitative Treatment Limits: # outpatient visits
Non-Quantitative Treatment Limits (NQTLs): preauthorization of services, utilization reviews, Rx drug formulary
design, fail-first policies
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
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
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
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!
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”
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
Texas Parity Advocacy
Categories of Advocacy
• Regulatory
• Consumer
• Provider
• Legislative
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
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?
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
TDI’s Regulatory Scope
TDI’s 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
Texans by Coverage Type
TDI-Regulated Market
TDI only
regulates fully
insured individual
and employer
coverage
Does TDI Regulate a Plan?
If “TDI” or “DOI” is on the
insurance card:
YES
Mission
TDI’s 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
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
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)
Form Review
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
Understanding Coverage
• TexasHealthOptions.com provides a guide to help
consumers understand insurance documents, costsharing, 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
Policy Documents
Your insurance policy is the primary source for
understanding what is covered and how it’s 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
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
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 TDI’s Consumer Help Line for assistance:
• Toll free: 1-800-252-3439
• Austin: 512-463-6515
• A formal complaint must be written (paper or electronic)
TDI Complaint Process
1.
Upon receipt, prioritize complaints according to nature, severity,
and industry impact; appropriately note confidential information
2.
Respond to customer, forward to regulated entity, review
response (due in 10 days), and research issue as necessary
3.
Screen issues for referral:
• identify “frivolous,” justified, and unjustified complaints
• check for potential enforcement, fraud, or market conduct
referrals
• check for consumer education issues
4.
Finalize response to customer (30 days, on average)
• Respond with informational/educational content and copy
regulated entity on TDI’s closing letter as appropriate
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 TDI’s investigation reveals a violation, TDI may
initiate an enforcement action
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
Contact TDI
• Consumer Protection Help Line: 1-800-252-3439
• Consumer Protection:
consumerprotection@tdi.texas.gov
• Rachel Bowden:
rachel.bowden@tdi.texas.gov
Questions?