Transcript Powerpoint Presentation - California State Association of

Parity 101:
What does it Mean for
Behavioral Health Services?
Sandra Naylor Goodwin, PhD, MSW
California Institute for Mental Health
June 2, 2011
Prevalence
• 1 in 5 CA adults experiences a mental
disorder; 1 in 25 symptoms of a serious
mental illness
• 1 in 10 CA adults abuses or is
dependent on alcohol or drugs
• 9-13% of CA children and youth between
ages 9-17 have a serious emotional
disturbance (SED) accompanied by a
substantial functional impairment
Faces of Medicaid III: Refining the
Portrait of People with Multiple
Chronic Conditions
• Fewer than 5% of beneficiaries account for
more than 50% of overall Medicaid costs
• 49% of Medicaid beneficiaries w disabilities
have a psychiatric illness
• 36% of Medicaid beneficiaries who are seniors
have a psychiatric illness
– October 2009 Center for Healthcare Strategies
Faces of Medicaid III (cont)
• 75% of Medicaid costs = 3 or more
chronic conditions
• Psychiatric illness is represented in 3 of
the top 5 most prevalent pairs of
diseases among the highest-cost 5% of
Medicaid-only beneficiaries with
disabilities
Faces of Medicaid III
Basics of Parity
• Mental health and substance use benefits in
health insurance have historically been less
generous than other physical illnesses.
• Parity is a response to this disparity, refers to
the concept that MH & SU coverage is to be
offered on par with covered medical and
surgical benefits.
Federal Parity Law
• Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008
(MHPAEA) Public Law 110-343
– Law: Mental Health and Substance Use
Services must be provided at parity with
general healthcare services
• no discrimination
– No mandate to cover MH or SU
– However, if any MH or SU benefit is provided,
all must be provided at parity
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Requirements/Limitations
• Financial requirements – e.g., deductibles,
copayments, coinsurance, out-of-pocket maximums
• Treatment limitations – limit benefits based on
frequency of treatment, number of visits, days of
coverage, days in a waiting period, and “other similar
limits on the scope and duration of treatment”.
– Quantitative treatment limitation – expressed
numerically, e.g., annual limit of 50 outpatient visits
– Non-quantitative treatment limitation – not
expressed numerically but otherwise limits the
scope or duration of benefits
Requirements/Limitations
• All comparisons of benefits must be
within the six categories:
– Inpatient, in-network
– Inpatient, out-of-network
– Outpatient, in-network
– Outpatient out-of-network
– Emergency care
– Prescription drugs
Federal Parity Law
• Interim Final Regs issued February 2, 2010
(75 Fed. Reg. 5410)
– Applies to group health plans for plan years
beginning on or after July 1, 2010
– Does not apply to plans insuring small businesses
(less than 50)
– Medi-Cal: applies to Managed Health Care, PrePaid Inpatient Health Plans, CHIP (Healthy
Families)
• Regulations governing the rest of Medi-Cal to
be out this year
Patient Protection & Affordable Care Act
Healthcare & Ed Reconciliation Act
• Expands the reach of the applicability of
federal parity law in 2014
– To qualified health plans established by PPACA
– Medicaid non-managed care benchmark and
benchmark equivalent plans
– Plans offered thru the individual market
• Creates a mandate to provide certain MH &
SU services
– To be created thru rulemaking
California
• Benchmark health plans
– CA Health Insurance Exchange Board must
define scope of MH & SU benefits within
federal guidelines and parity
• Indigent Adults without Disabilities or
Children:
– Must define scope of MH & SU within
federal guidelines
California
• Definition of substance use disorders:
– CA must define at what point SU becomes a
medical issue that requires treatment and
what services will be offered
• Mental Health Services:
– CA counties provide mental health services
thru a Medi-Cal Pre Paid Inpatient Plan
– Does this equate to parity for county
sponsored Medi-Cal Managed Care?
CA 1115 Waiver Conditions
Behavioral Health Services Assessment - By March 1, 2012, the
State will submit to CMS for approval an assessment that shall
include information on available mental health and substance
use service delivery infrastructure, information system
infrastructure/capacity, provider capacity, utilization patterns and
requirements (i.e., prior authorization), current levels of
behavioral health and physical health integration and other
information necessary to determine the current state of
behavioral service delivery in California.
Behavioral Health Services Plan - By October 1, 2012, the State
will submit to CMS for approval a detailed plan, including how the
State will coordinate with the Department of Mental Health and
Alcohol and Drug Programs outlining the steps and infrastructure
necessary to meet requirements of a benchmark plan no later
than 2014.
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