1
LEGAL & POLICY
IMPLICATIONS FOR
TREATMENT IN 2014 &
BEYOND
Carol McDaid
Capitol Decisions, Inc.
February 10, 2014, AXIS Conference
Overview of the Presentation
2
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Parity & ACA: Legal & Policy Implications for Treatment for 2014 &
Beyond
 Parity
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Federal parity implementation: a chronology
Opportunities & challenges
Why is parity important to treatment providers?
Key provisions in MHPAEA Final Rule
Tools for providers: MHPAEA implementation & enforcement
Implications for providers & facilities
Changing business practices to optimize MHPAEA & ACA
Affordable Care Act
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Medicaid expansion
The Exchanges
Parity & ACA Chronology
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The Mental Health
Parity & Addiction
Equity Act
(MHPAEA) becomes
law; fully effective
1/1/2011
2008
EHB rule requires
SUD as 1 of the 10
essential benefits.
Parity applied in & out
of exchanges to nongrandfathered plans
2010
The Affordable Care Act
(ACA) becomes law
CMS issues guidance
applying parity to
MMCOs & CHIP
unless state plan
permits discriminatory
limits
2013
MHPAEA final rule released
on 11/8/13; applies only to
commercial plans
Opportunities
4
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Largest expansion of addiction coverage and
reimbursement in a generation
Medicalization, not criminalization, of substance use
disorders
Stigma and discrimination reduced
Equitable reimbursement and provider networks for
providers and specialists
Challenges
5
Like building and flying an airplane at the same time
Challenges in Detail
6
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26 states expanding Medicaid
Highly politicized environment in state-federal
structure
Less than ½ of states fully implementing ACA
Much of the promise of parity & ACA based on
state decision-making
Landmark laws historically take decades for full
implementation
7
Why is parity important to
treatment providers?
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Coverage ≠ access
MHPAEA requires parity in care management; most state
parity laws do not
Parity provides a rationale for equitable use of MAT for
SUD
Without parity, behavioral health cost shift from private to
public sector continues while federal funding drops due to
ACA
Rationale for equal levels & types of care in hostile
reimbursement environment
Strategy: Encourage DOI to do annual MHPAEA
compliance audit like Connecticut’s
MHPAEA Final Rule: Who & When
8
•
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•
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The rule does not apply to Medicaid managed
care, CHIP and alternative benefit plans (more
guidance is coming) but law does
Continues to allow local & state self-funded plans
to apply for an exemption from MHPAEA
Applies to the individual market (grandfathered &
non-grandfathered plans)
Effective for plan years on or after 7/1/14
(1/1/15)
MHPAEA Does Not Apply To
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Medicare
 Traditional fee-for-service Medicaid
 FEHBP
 TRICARE
 VA
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MHPAEA Final Rule: Scope of
Services
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Big win for intermediate services (IOP, PHP,
residential)
Clarified scope of services issue by stating:
6 classification benefits scheme was never intended to
exclude intermediate levels of care
 MH/SUD services have to be comparable to the range &
types of treatments for medical/surgical within each class
 Plans must assign intermediate services in the behavioral
health area to the same classification as plans or issuers
assign intermediate levels for medical/surgical
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MHPAEA Final Rule: NQTLs
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Strikes provision that permitted plans to apply limits if
there was a “clinically recognized standard of care
that permitted a difference”
NQTLs are expanded to include geographic location,
facility type, provider specialty & other criteria (i.e.
can’t let patients go out of state for med/surg
treatment and not MH/SUD)
Maintains “comparably & no more stringently”
standard without defining the term
Confirms provider reimbursement is a form of NQTL
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MHPAEA Final Rule: Disclosure &
Transparency
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Requires that criteria for medical necessity
determinations be made available to any current or
potential enrollee or contracting provider upon request
Requires the reason for a denial be made available
upon request
Final rule now requires plans to provide written
documentation within 30 days of how their processes,
strategies, evidentiary standards & other factors were
used to apply an NQTL on both med/surg & MH/SUD
MHPAEA Final Rule: Enforcement
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Final rule clarifies that, as codified in federal &
state law, states have primary enforcement over
health insurance issuers
DOL has primary enforcement over self insured
ERISA plans
DOL, HHS & CMS will step in if a state cannot or
will not enforce the law
Implications
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Laws are not self-implementing
Coordinated effort between providers, patients &
industry to fully implement & enforce
groundbreaking laws
Requires well coordinated networks at state &
federal level with common messaging
Sharing effective ACA & parity implementation
strategies & replicating successes
Strategy: Urge providers & consumers to engage
in parity education & advocacy
Changing Business Practices to
Optimize Parity
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Benefit Verification
 Patients
should sign release permitting treatment center
to be their “authorized representative” with health plan
for purposes of obtaining plan documents
 As authorized rep, seek a complete copy of patient’s
health plan – to compare medical & behavioral benefit
 Train benefit verification staff on MHPAEA final rule
prior to its full implementation date (plan years on or
after 7/1/14)
MHPAEA Training at All Levels
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Benefit verification staff
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Clinical Staff
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Training should include: quantitative & non-quantitative treatment limits,
scope of services, prohibitions on facility type & geographic limitations
Staff should know & tell self-insured plans employer is liable for
MHPAEA violations
Regularly appeal denied claims; templates available at
www.parityispersonal.org
Documentation must conform to medical necessity criteria
Senior staff
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Should be trained in basics of MHPAEA; market will not change unless
we are informed ambassadors & drive change
State & Local Advocacy
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State and local advocacy must be better
coordinated to drive state and federal enforcement
of MHPAEA and ACA
State and national trade associations should have
common goals and strategies for parity & ACA
implementation and enforcement
Resources
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Resources available at
www.parityispersonal.org:
 URAC
parity standards
 Massachusetts parity guidance
 Connecticut compliance survey
 Maryland parity laws
 Nebraska parity compliance checklist
 Milliman employer & state guide to
parity compliance
 Toolkit for appealing denied claims
Additional Resources
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States & public plans
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CMS Center for Consumer Insurance Information & Oversight (CCIIO)
877-267-2323 ext 61565
E-mail: Phig@cms.hhs.gov
Employer plans
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DOL Employee Benefits Administration
866-444-3272
www.askebsa.dol.gov
Affordable Care Act & Parity
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On 1/1/14*, ACA expanded MHPAEA & parity
applies to:
 Benefits provided in new “exchanges”
 Benefits provided by non-grandfathered small
group & individual plans
 Benefits provided to new Medicaid population
 These plans will have to offer a MH/SUD benefit
*The Administration is allowing canceled plans (that
didn’t meet these requirements) to continue to be
offered in 2014; adherence will vary by state
Controversial ACA Provisions
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“If you like your plan, you
can keep it”
Medical device tax
2.3% tax on health plans
Individual mandate & fines
Coverage for
contraceptives
Who is enrolling in the exchanges?
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65 percent previously uninsured
More than one-third have not had a check-up for more than
two years
Lower income than those currently covered by private
insurance
More racially diverse than the those who currently have
private insurance
One in four Exchange enrollees speak a language other
than English at home
77 percent of people enrolled through Exchanges have a
high school diploma or less
Showing Signs of Improvement, Federal Exchange Numbers
and Total ACA Enrollment Spiked in December
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Health Insurance Exchange Enrollment by Month
State exchanges
Oct. 2013
Nov. 2013
Analysis
Federal exchanges
Dec. 2013
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Monthly Total:
1,788,739
•
•
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Monthly Total:
106,185
Monthly Total:
258,497
•
In December, there was a sevenfold
increase in federal exchange enrollments
In December, there was a threefold
increase in state exchanges
While state exchanges saw the most
success in the opening two-month
period, total enrollment in the federal
exchange now outpaces total enrollment
in state-based exchanges by 25%
The rise in enrollment is due in large
part to Dec. 24 deadline for Jan. 1
coverage and technical repairs to
HealthCare.gov
Overall, ACA enrollment in both state
and federal exchanges have undergone a
fivefold increase; 1,788,739 additional
people selected plans in December
The cumulative, three-month ACA
enrollment total is 2,153,421 people
Source: Department of Health and Human Services, 2013; Sam Baker, “Three Things You Should Know About the Latest
Obamacare Numbers,” National Journal, January 13, 2014.
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What can you “buy” on the
exchanges?
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“Qualified Health Plans” (QHPs)
Private insurance plans
 Must cover “essential health benefits”
 Must offer certain levels of value (“metal levels”)
 Must include “essential community providers,” where
available, in their networks
 Must have provider network sufficient to ensure access to
MH/SUD services without “unreasonable delay”
 Must comply with ACA insurance reforms
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Strategy: Get copies of QHP benefit packages & verify
packages are ACA & MHPAEA compliant
How MHPAEA Applies to Exchanges
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25
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Per recent guidance:
Plans offered in the exchanges will be required to offer a
mental health & addiction benefit at parity
 “New” individual & small group plans (plans not in existence
on 3/23/10) will also have to offer mental health and
addiction at parity
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ACA data regs require plans to report on quantitative
treatment limitations
MHPAEA guidance requires reporting of NQTLs
Strategy: Make sure exchange requires QHP reporting of
BH financial & other treatment limits
Parity & Medicaid Expansion
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January 2013 Medicaid parity guidance
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Medicaid MCO plans must comply w/parity unless state plan allows
discriminatory limits
Benefits for the “newly eligible” Medicaid population must include
MH/SUD at parity
Parity final rule does not apply to MMCOs, CHIP & ABPs
PIC asking for new guidance on application of final rule within
6 months or by 7/1/14
CMS guidance available at:
http://www.medicaid.gov/Federal-Policy-
Guidance/Federal-Policy-Guidance.html
Strategy: Advocate for CMS parity guidance applying
final rule by 7/1/14
Questions?
27
Carol McDaid
cmcdaid@capitoldecisions.com
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UNDERSTANDING AND
IMPLEMENTING NEW
LEGAL REQUIREMENTS
Anelia Shaheed
Med Pro Billing
February 10, 2014, AXIS Conference
Overview of the Presentation
29
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What will the ACA do to my business ?
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New Patients, Policies and Coverage?
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New Legal Requirements by the State and Federal Govt?
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What will the expansion of Medicare/Medicaid do to my business ?
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What should I expect from Insurance Companies ?
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In Reimbursement
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Performance Requirements
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Utilization Review and Medical Records
What am I as a provider required to comply with ?
Overview of Insurance
30
Benefits
Verifications
Utilization
Review
Billing and
Collections
Importance of Understanding Legal and
Ethical Business Operations
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Whether New or Experienced, every provider in
every sector of the mental health and substance
abuse industry will undergo changes in the
upcoming years.
It is important that all areas of your business meet
your state and federal guidelines for ethical and
legal compliance
Mental Health and Substance Abuse is moving into the
realm of national scrutiny
What will the ACA do to my Business?
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New Patients and New Policies
ACA policies vary by state, depending on whether
they have initiated own state policies or adopted
Federal polices
If you take insurance now you can continue taking
these policies
These policies have both IN and OUT of network
benefits
What will the ACA do to my Business?
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As of today there is no change in Medicare
recognizing Medicare allowables for primary
substance abuse diagnosis in a facility setting
Insurance companies have reporting requirements to
participate and performance requirements which
means those restrictions will be passed along to you.
 Increase
in number of medical records and third party
audits.
 This can be a good thing !
What will the ACA do to my Business?
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
Under ACA, you do not have to be a Medicare or
Medicaid provider in your state to perform services
for policies that are sold under the exchanges.
 Normal
state licensing or insurance company
requirements will still apply and may be come more
stringent
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Under ACA, you can continue to accept self-pay
and cash payments
 However,
if you are balance billing or offering
scholarship you must legally compliant with the
provision of the Act
Legal Requirements for Balance Billing
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Medicare and Medicaid Patients and Providers
 Some
states and plans specifically prohibit amount that
may be balanced billed by providers if assignment is
on file
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Notice of Balance Billing and Collections
 Any
Bill, Statement or Attempt to collect even if by a
provider should be compliant with the Fair Debt
Collections Act
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In- Contracts strictly can prohibit balance billing
Legal Requirements for Marketing and
Scholarships
36
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Healthcare Enticement and Kickbacks
 Scrutiny
of ownership interest in business (check with
your state)
 Federal requirements – must be for services rendered
not just referrals
 State requirements – specific states have guidelines for
Kickbacks
 Write Off/ Scholarships
What should I be careful of?
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Increased scrutiny by Insurance Companies
Increase in no of audits / medical records
Increase in no of individuals covered by gov’t
funding which means as a provider requirement to
be compliant with Federal/State req.
Decrease in willingness to contract
Decrease in traditional methods of service by
insurance companies (HITECH)
What will the Expansion of
Medicaid Do for MH/SA
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Short Answer…. Increase in individuals covered Not
be an immediate source or revenue
If you choose to provide service these individuals all
Federal and State practices and requirements
apply
New carve-outs through private insurance
companies (ValueOptions/BCBS) for
Medicaid/Medicare
What will Insurance Companies Do?
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2013 – Delay of large group implementation /
Drops of single individual policies
2013 – Majority of commercial insurance
companies will treat ACA policies as commercially
priced services
Expect the continuation and increase in allowables
(are allowables legal ????)
2014 – Implementation of Large Group
What will Insurance Companies Do?
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What will affect Reimbursement Models
 Allowables and Usual and Customary… what do
these mean legally?
 Disclosure requirements.. I can get information on
behalf of the patient but how?
 Reporting requirements.. Insurance companies can
loose their ability to sell policies and must report
information to gov’t.
What will Insurance Companies Do?
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What will affect Reimbursement Models
 Provider contact with Insurance Companies
 Utilization Review is going to be difficult /
published criteria and ability to appeal
 CARF and JACHO and other new policy restrictions
A Business What Do I need to Do?
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Financially
 Valid and Accurate Licensure from State
 Clear Financial Documentation for Billing Insurance
and Self Pay compliant with federal and state
guidelines
 Clear authorization to legally act on behalf patients
and subscribers
 Clear documentation and procedures for handling
patient information
A Business What Do I need to Do?
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Clinically
 Appropriate Licensure for Clinically staff, scheduling
and oversight
 A GOOD MEDICAL RECORD (documentation of
medical necessity)
A Business What Do I need to Do?
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Administrative / Accounting
 Clear and Compliant protocol for statements,
balance billing and scholarship (must be Federal
and specific to the state you perform services)
 Clear protocols for collection efforts
 Documented audits and procedures for ensuring
insurance billing compliance
 Documented procedures for hardship letters
 Tracking your receivables !
A Business What Do I need to Do?
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Administrative / Marketing
 Copyright and Trademark protection
 If using a third party vendor / clear distinct
separation from organization and contractual
compliance with state guidelines
 If using a employee / clear documentation that
employee is not being paid for referral but for
employee related services
A Business What Do I need to Do?
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Administrative / CEO Liability
 Ensure proper and legal authorities in your state
retain ownership interest (Dr. v. Individuals)
 Limited Liability ! (LLP, LLC)
 Proper Liability Insurance, EPI Insurance, HIPAA and
HITECH insurance, PL insurance
 Proper administrative safe guards in place for all
areas of the business… provided by a good
attorney and accountant who KNOWS
HEALTHCARE
Questions?
47
Med Pro Billing
1-800-990-0340
www.medprobill.com
Melissa Zachariasz
mzachariasz@medprobill.com
President
Anelia Shaheed, Esq.
ashaheed@medprobill.com